Migraine Medications in Pregnancy

Aka: Migraine Medications in Pregnancy, Headache Medications in Pregnancy

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II. Management: Migraine Headache Abortive Medications

  1. See Migraine Abortive Management
  2. Sample protocol
    1. Mild to Moderate Migraine
      1. See Nonpharmacologic Headache Treatment
      2. Acetaminophen (Tylenol) 1000 mg orally up to three times daily
    2. Moderate to Severe Migraine
      1. Metoclopramide (Reglan) 10 mg orally
      2. Ibuprofen or Naproxen (second trimester only)
        1. Do NOT use in first or third trimester
      3. Acetaminophen (Tylenol)
      4. Consider Caffeine (limit to 200-300 mg/day during pregnancy)
    3. Severe Migraine with Vomiting (outpatient)
      1. Compazine or Phenergan suppository PR
      2. Consider Prednisone
      3. Consider Opioid Analgesic (e.g. Vicodin)
    4. Severe Migraine with Dehydration (admitted, L&D or Emergency department)
      1. Intravenous Fluid Replacement
      2. Metoclopramide (Reglan) 10 mg IV slowly
      3. Prochloroperazine (Compazine) 10 mg IV slowly
      4. Triptans
        1. Avoid in first trimester (fetal malformations and adverse pregnancy outcomes)
        2. Risk of uterine atony and peripartum Hemorrhage
        3. Sumatriptan (Imitrex) may be considered in debilitating Headache (see below)
      5. Consider Ketorolac (Toradol) in second trimester only
      6. Consider Magnesium 1 to 2 g IV over 20 min
      7. Consider intravenous Morphine
      8. Consider intravenous Methylprednisolone
        1. Avoid Dexamethasone due to fetal exposure
  3. 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 (and other NSAIDs)
      1. Historically Pregnancy Category B (D in third trimester)
      2. Do NOT use in first or third trimester (PDA risk)
      3. May be used in second trimester with caution
  4. Opioid Analgesics
    1. Relatively safe in limited use
    2. However, not recommended in general
      1. Opioid Dependence Risk
      2. Medication Overuse Headache
      3. Neonatal Opioid Withdrawal syndrome
    3. Agents
      1. Morphine: B
      2. Hydrocodone (Vicodin): C
  5. Triptans (e.g. Sumatriptan)
    1. Sumatriptan (Imitrex) is Pregnancy Category C
      1. Other Triptans have insufficient safety data in pregnancy
    2. Not recommended for routine use in pregnancy
    3. Consult obstetrics before use
    4. May be considered if Migraines are uncontrolled, debilitating
    5. Adverse effects in pregnancy
      1. Avoid in first trimester (fetal malformations and adverse pregnancy outcomes)
      2. Risk of uterine atony and peripartum Hemorrhage (but may be considered in debilitating Headache)
      3. Associated with hyperactivity and emotionality at age 3 in exposed children (AHRQ)
      4. Nezvalova-Henriksen (2010) Headache 50(4): 563-75 [PubMed]

III. Management: Migraine Headache Prophylactic Medications

  1. See Migraine Headache Prophylaxis
  2. Indications
    1. Intractable, frequent Migraine Headaches
    2. Vomiting and Dehydration due to persistent Migraines
  3. Most prophylactic agents are contraindicated
    1. Avoid Tricyclic Antidepressants
    2. Avoid anticonvulsants (e.g. Valproic Acid)
  4. Prophylactic medications that are considered safe
    1. Magnesium Oxide 400 to 800 mg orally daily
      1. Mazza (2022) Arch Gynecol Obstet +PMID: 36495328 [PubMed]
  5. 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. Avoid Topiramate
      3. Avoid Valproic Acid
    5. Other agents
      1. Avoid Vitamin B2

IV. Management: Cluster Headache

  1. See Cluster Headache
  2. Uncommon in women and rare in pregnancy
  3. Management options (safer regarding pregnancy)
    1. Supplemental Oxygen (high flow)
    2. Sumatriptan (intranasal and subcutaneous)
      1. Avoid in first trimester (fetal malformations and adverse pregnancy outcomes)
      2. Risk of uterine atony and peripartum Hemorrhage (but may be considered in debilitating Headache)
    3. Verapamil
    4. Prednisone or Prednisolone
    5. Gabapentin (Neurontin)
  4. References
    1. Jurgens (2009) Cephalgia 29(4): 391-400 [PubMed]

V. References

  1. Johnson (2004) Prim Care Clin Office Pract 31:417-28
  2. Mayans (2018) Am Fam Physician 97(4): 243-51 [PubMed]
  3. Modi (2006) Am Fam Physician 73(1):72-80 [PubMed]
  4. Silberstein (2004) Neurol Clin 22:727-56 [PubMed]

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