Migraine Medications in Pregnancy

Aka: Migraine Medications in Pregnancy, Headache Medications in Pregnancy

1. See Also
   1. Headache in Pregnancy
   2. Headache Medications in Lactation
2. Migraine Headache Abortive Medications
   1. Sample protocol
      1. Mild to Moderate Migraine
         1. See Nonpharmacologic Headache Treatment
         2. Acetaminophen (Tylenol)
      2. Moderate to Severe Migraine
         1. Metoclopramide (Reglan) 10 mg orally
         2. Ibuprofen or Naproxen (not in third trimester)
         3. Acetaminophen (Tylenol)
         4. Consider Caffeine (limit to 300 mg/day during pregnancy)
      3. Severe Migraine with Vomiting (outpatient)
         1. Compazine or Phenergan suppository PR
         2. Consider Prednisone
         3. Consider Narcotic Analgesic (e.g. Vicodin)
      4. Severe Migraine with dehydration (admitted)
         1. Intravenous fluid replacement
         2. Prochloroperazine (Compazine) 10 mg IV
         3. Consider intravenous morphine
         4. Consider intravenous Methylprednisolone
   2. Safe Medications (with FDA Pregnancy Categories)
      1. Acetaminophen (Tylenol): B
      2. Metoclopramide (Reglan): B
      3. Prochloroperazine (Compazine): C
      4. Promethazine (Phenergan): C
      5. Ibuprofen or Naproxen: B (D in third trimester)
         1. Do not use in third trimester (PDA risk)
   3. Narcotic Analgesics (relatively safe in limited use)
      1. Morphine: B
      2. Meperidine (Demerol): B
      3. Hydrocodone (Vicodin): C
      4. Codeine (Tylenol #3): C
   4. Triptans (e.g. Imitrex): C
      1. Not recommended for use in pregnancy
      2. Consult obstetrics before use
      3. May be considered if Migraines are uncontrolled
      4. Review suggests no significant adverse fetal effects
         1. Fox (2002) Headache 42:8-15
3. Migraine Headache Prophylactic Medications
   1. Indications
      1. Intractable, frequent Migraine Headaches
      2. Vomiting and dehydration due to persistent Migraines
   2. Most prophylactic agents are contraindicated
      1. Avoid Tricyclic Antidepressants
      2. Avoid anticonvulsants (e.g. Valproic Acid)
   3. Prophylactic medications that might be considered
      1. Use with obstetric and neurology consultation
      2. Antidepressants
         1. Fluoxetine (Prozac): B
      3. Antihypertensives
         1. May be considered in early pregnancy
            1. Later pregnancy use may cause IUGR
         2. Agents (use with caution)
            1. Beta Blockers (category D late in pregnancy)
               1. Labetolol 150 mg PO twice daily
               2. Propranolol: C
               3. Metoprolol (Toprol): C
               4. Avoid Atenolol: Category D throughout pregnancy
            2. Calcium Channel Blockers
               1. Verapamil
            3. Antihypertensives contraindicated in pregnancy
               1. Avoid Lisinopril
               2. Avoid Candesartan
               3. Avoid Atenolol
      4. Anticonvulsants
         1. Gabapentin: C
         2. Topiramate: C
         3. Avoid Valproic Acid
      5. Other agents
         1. Avoid Vitamin B2
4. References
   1. Johnson (2004) Prim Care Clin Office Pract 31:417-28
   2. Modi (2006) Am Fam Physician 73(1):72-80
   3. Silberstein (2004) Neurol Clin 22:727-56