Treatment of migraine in pregnancy

(Date of issue: August 2016. Version: 2.1)

This factsheet has been written for members of the public by the UK Teratology Information Service (UKTIS). UKTIS is a not-for-profit organisation funded by Public Health England on behalf of UK Health Departments. UKTIS has been providing scientific information to health care providers since 1983 on the effects that medicines, recreational drugs and chemicals may have on the developing baby during pregnancy.

What is migraine?

Migraines are severe headaches often accompanied by nausea and visual disturbances, and are commonly experienced by women of childbearing age.

Is it safe to use migraine treatments in pregnancy?

There is no yes or no answer to this question. When deciding whether to use migraine treatments during pregnancy it is important to weigh up how necessary a treatment is for your condition against any possible risks to you or your baby, some of which might depend on how many weeks pregnant you are.

What is the recommended treatment for migraine in pregnancy?

Many women find that migraine attacks become less severe and/or less frequent during pregnancy, meaning that specific migraine treatments or use of long-term medicines to prevent migraine may no longer be required. Your doctor is the best person to help you decide what is right for you and your baby.

Non-drug treatment options
Some women can manage their migraines without medicines, using techniques such as:
• Avoiding triggers for migraine (including stress and certain foods)
• Relaxation and deep breathing techniques
• Getting enough sleep
• Massage
• Use of ice packs

Drug treatments for pain during a migraine attack
Use of the following medicines, either alone or in combination, may be suggested by your doctor depending on how severe your migraine attack is and how well you respond to a particular treatment. Separate bump leaflets are available for most of these medicines to help you to weigh up the risks and benefits of use in pregnancy in discussion with your doctor.

Paracetamol is regarded as the treatment of choice for mild to moderate pain in pregnancy. It has a good overall safety profile based on a large number of pregnant women studied, and although possible links with autism and ADHD in children who were exposed in the womb have been suggested, these remain unproven. It is also important to remember that no other painkiller is considered to be any safer for use in pregnancy. For more information please see the bump leaflets on paracetamol use in pregnancy.

Non-steroidal anti-inflammatory drugs (NSAIDS) can be used in the first and second trimesters if paracetamol does not control pain adequately. NSAIDS should not be used after 30 weeks of pregnancy as, after this stage they may affect the wellbeing of the baby. For more information please see the bump leaflets on ibuprofen use in pregnancy, diclofenac use in pregnancy, and naproxen use in pregnancy.

Sumatriptan may be suggested if paracetamol has not controlled your pain and use of a NSAID is not advisable (for example in the third trimester). There is currently no evidence that use of sumatriptan in pregnancy is harmful to the developing baby, but more information needs to be collected to confirm this. The human pregnancy information that is available is summarised in our bump leaflet sumatriptan use in pregnancy to help you make an informed choice.

Codeine has a number of side effects and use in pregnancy, especially in the weeks leading up to delivery, can result in withdrawal symptoms in the baby after birth. It may therefore only be offered by your doctor if the previous treatment options have not worked, are not suitable for you, or could not be used. Further information on the fetal effects of use in pregnancy can be found in our codeine use in pregnancy bump leaflet.

What can I take if I have nausea and vomiting with my migraine?

Metoclopramide is an anti-sickness medicine that may be suggested if you have nausea and vomiting with your migraine. Metoclopramide is often used to treat pregnancy sickness. It is not known to be harmful to a developing baby, but because there are not many human pregnancy studies, more research is needed to confirm this. The available scientific information on fetal safety is summarised in our bump leaflet treatment of nausea and vomiting in pregnancy.

Can I continue to take my migraine prevention medicines during pregnancy?

Because migraines often improve with pregnancy, the need for continuing a medicine to prevent migraine attacks should be reassessed in consultation with your doctor. It is currently advised that, where possible, preventative medicines are stopped and that migraines are treated (using the options listed above) as they occur. However, women who suffer from severe or frequent migraines may need to consider treatment to prevent migraine attacks in pregnancy.

Which migraine prevention medicines can be considered for use during pregnancy?

Low dose aspirin, propranolol, amitriptyline and verapamil are known to be effective in preventing migraine in the non-pregnant population and have been used in pregnancy for various other conditions. If you and your doctor feel that a migraine prevention medicine is necessary during pregnancy it would be advisable to consider one of the above medicines, taking into account what is known about how the medicine may affect a baby in the womb.

Acupuncture can also be effective in the prevention of migraine. Although no studies have been carried out to investigate the safety of its use during pregnancy, it is not expected to put a baby at risk, but should always be carried out by a licensed acupuncturist. 

Why are some migraine prevention and treatment medicines not first choice during pregnancy?

Some medicines (for example, topiramate, riboflavin, gabapentin, pizotifen, venlafaxine, botulinum toxin, magnesium citrate, and coenzyme Q10) are used to treat and prevent migraine in non-pregnant individuals, but are not generally advised for use in pregnancy. This is either because there is very little human pregnancy safety information, or because some studies have suggested that use at certain stages of pregnancy might affect the baby. However, in some individual cases, a doctor or specialist might suggest use of one of these medicines, for example, if other treatments have not worked and the migraine is significantly affecting the health and well-being of the mother and therefore her unborn baby. The over-the-counter medicine Migraleve (which contains paracetamol, codeine, and an anti-sickness medicine called buclizine) should only be used in pregnancy on advice from a doctor. This is because there is very little pregnancy safety information about buclizine.

Are there any migraine prevention medicines that should NOT be used during pregnancy?

Sodium valproate and a family of medicines called ACE inhibitors (including captopril, cilazapril, enalapril, fosinopril, imidapril, lisinopril, moexipril, perindopril, quinapril, ramipril and trandolapril) should not be used to prevent migraine in pregnant women. This is because sodium valproate can cause birth defects and learning problems in the baby, and ACE inhibitors used after around 14 weeks of pregnancy can cause a reduction in amniotic fluid levels and damage the baby’s kidneys. If you are currently being treated with either of these medicines and are pregnant it is important to arrange an appointment with your doctor as soon as possible to discuss changing your treatment.

If you are planning a pregnancy at any stage in the future and take these medicines it is advisable to use reliable contraception until you have discussed your plans with your doctor.

What if I have already used migraine treatments during pregnancy?

If you have taken any medicines it is always a good idea to let your doctor know that you are pregnant so that you can decide together whether you still need your medicines, that you are taking the lowest dose that works, or whether your medication might need to be altered. It is important that women who become pregnant while taking sodium valproate or an ACE inhibitor to prevent migraine consult their doctor as soon as possible as their medicine will need to be reviewed and altered if treatment is still required. Additionally, because both sodium valproate and ACE inhibitors can affect the baby, extra antenatal scans and monitoring of the baby after birth may be advised.

Who can I talk to if I have questions?

If you have any questions regarding the information in this leaflet please discuss them with your health care provider. They can access more detailed medical and scientific information from www.uktis.org.

General information 

Up to 1 out of every 5 pregnancies ends in a miscarriage, and 1 in 40 babies are born with a birth defect. These are referred to as the background population risks.  They describe the chance of these events happening for any pregnancy before taking factors such as the mother’s health during pregnancy, her lifestyle, medicines she takes and the genetic make up of her and the baby’s father into account.

Medicines use in pregnancy

Most medicines used by the mother will cross the placenta and reach the baby. Sometimes this may have beneficial effects for the baby.  There are, however, some medicines that can harm a baby’s normal development.  How a medicine affects a baby may depend on the stage of pregnancy when the medicine is taken. If you are on regular medication you should discuss these effects with your doctor/health care team before becoming pregnant.

If a new medicine is suggested for you during pregnancy, please ensure the doctor or health care professional treating you is aware of your pregnancy.

When deciding whether or not to use a medicine in pregnancy you need to weigh up how the medicine might improve your and/or your unborn baby’s health against any possible problems that the drug may cause. Our bumps leaflets are written to provide you with a summary of what is known about use of a specific medicine in pregnancy so that you can decide together with your health care provider what is best for you and your baby.   

Every pregnancy is unique. The decision to start, stop, continue or change a prescribed medicine before or during pregnancy should be made in consultation with your health care provider. It is very helpful if you can record all your medication taken in pregnancy in your hand held maternity records.

   

www.medicinesinpregnancy.org

Disclaimer: This information is not intended to replace the individual care and advice of your health care provider. New information is continually becoming available. Whilst every effort will be made to ensure that this information is accurate and up to date at the time of publication, we cannot cover every eventuality and the information providers cannot be held responsible for any adverse outcomes following decisions made on the basis of this information. We strongly advise that printouts should NOT be kept for any length of time, or for “future reference” as they can rapidly become out of date.

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