II. Management: Migraine Headache Abortive Medications
- See Migraine Abortive Management
- Sample protocol
- Mild to Moderate Migraine
- Moderate to Severe Migraine
- Metoclopramide (Reglan) 10 mg orally
- Ibuprofen or Naproxen (not in first or third trimester)
- Acetaminophen (Tylenol)
- Consider Caffeine (limit to 300 mg/day during pregnancy)
- Severe Migraine with Vomiting (outpatient)
- Compazine or Phenergan suppository PR
- Consider Prednisone
- Consider Opioid Analgesic (e.g. Vicodin)
- Severe Migraine with Dehydration (admitted)
- Intravenous Fluid Replacement
- Prochloroperazine (Compazine) 10 mg IV
- Triptans
- Avoid in first trimester (fetal malformations and adverse pregnancy outcomes)
- Risk of uterine atony and peripartum Hemorrhage (but may be considered in debilitating Headache)
- Consider intravenous Morphine
- Consider intravenous Methylprednisolone
- Safe Medications (with FDA Pregnancy Categories)
- Acetaminophen (Tylenol): B
- Metoclopramide (Reglan): B
- Prochloroperazine (Compazine): C
- Promethazine (Phenergan): C
- Ibuprofen or Naproxen: B (D in third trimester)
- Do not use in first or third trimester (PDA risk)
-
Opioid Analgesics (relatively safe in limited use)
- Morphine: B
- Hydrocodone (Vicodin): C
-
Triptans (e.g. Imitrex): C
- Not recommended for routine use in pregnancy
- Consult obstetrics before use
- May be considered if Migraines are uncontrolled, debilitating
- Adverse effects in pregnancy
- Avoid in first trimester (fetal malformations and adverse pregnancy outcomes)
- Risk of uterine atony and peripartum Hemorrhage (but may be considered in debilitating Headache)
- Nezvalova-Henriksen (2010) Headache 50(4): 563-75 [PubMed]
III. Management: Migraine Headache Prophylactic Medications
- See Migraine Headache Prophylaxis
- Indications
- Intractable, frequent Migraine Headaches
- Vomiting and Dehydration due to persistent Migraines
- Most prophylactic agents are contraindicated
- Avoid Tricyclic Antidepressants
- Avoid anticonvulsants (e.g. Valproic Acid)
- Prophylactic medications that might be considered
- Use with obstetric and neurology Consultation
- Antidepressants
- Fluoxetine (Prozac): B
- Antihypertensives
- May be considered in early pregnancy
- Later pregnancy use may cause IUGR
- Agents (use with caution)
- Beta Blockers (category D late in pregnancy)
- Labetolol 150 mg PO twice daily
- Propranolol: C
- Metoprolol (Toprol): C
- Avoid Atenolol: Category D throughout pregnancy
- Calcium Channel Blockers
- Antihypertensives contraindicated in pregnancy
- Avoid Lisinopril
- Avoid Candesartan
- Avoid Atenolol
- Beta Blockers (category D late in pregnancy)
- May be considered in early pregnancy
- Anticonvulsants
- Gabapentin: C
- Topiramate: C
- Avoid Valproic Acid
- Other agents
- Avoid Vitamin B2
IV. Management: Cluster Headache
- See Cluster Headache
- Uncommon in women and rare in pregnancy
- Management options (safer regarding pregnancy)
- Supplemental Oxygen (high flow)
- Sumatriptan (intranasal and subcutaneous)
- Avoid in first trimester (fetal malformations and adverse pregnancy outcomes)
- Risk of uterine atony and peripartum Hemorrhage (but may be considered in debilitating Headache)
- Verapamil
- Prednisone or Prednisolone
- Gabapentin (Neurontin)
- References
V. References
- Johnson (2004) Prim Care Clin Office Pract 31:417-28
- Mayans (2018) Am Fam Physician 97(4): 243-51 [PubMed]
- Modi (2006) Am Fam Physician 73(1):72-80 [PubMed]
- Silberstein (2004) Neurol Clin 22:727-56 [PubMed]
