For women with migraine who become pregnant, some of these changes may be worrisome. Will migraine attacks become more frequent, and if so, is it possible to safely manage migraine pain when you’re expecting? There are a couple of different issues to consider when it comes to migraine and pregnancy, says Amaal Starling, MD, a neurologist and migraine specialist at the Mayo Clinic in Phoenix, Arizona. “One is a concern that if there’s a correlation between hormones and migraine, what is going to happen during pregnancy with migraine?” Spoiler alert: It’s actually pretty positive news, according to Dr. Starling. Here’s how being pregnant impacts migraine and what you can do to manage and even minimize migraine attacks when you’re expecting.
1. Are Migraines Attacks Common in Early Pregnancy?
One thing we know about hormones and migraine, specifically estrogen and migraine, is that changes in estrogen levels can lead to an attack, according to Starling. “Even though migraine is a genetic neurologic disease, it has many different triggers, and a drop in estrogen or change in estrogen level can be a trigger,” she says. “For that reason, some women may struggle during their first trimester during pregnancy, because there’s a lot of drastic changes in those estrogen levels,” says Starling.
2. Do Migraine Attacks Get Worse During the 2nd and 3rd Trimesters?
On the positive side, once you get into your second and third trimesters of pregnancy, your estrogen level is very stable, says Starling. “Because of that stability, migraine during the second and third trimesters of pregnancy will often go into remission or improve significantly,” she says. A prospective study published in The Journal of Headache Pain found that during pregnancy, women with migraine reported a gradual decrease in the frequency and duration of their migraine attacks. There is also data that shows that breastfeeding may be protective against developing more frequent and severe migraine attacks in the postpartum period, adds Starling. A study published in the journal Cephalalgia found that breastfeeding “seemed to protect from migraine recurrence during postpartum,” according to the authors. “If a medication is needed, usually my first choice is to start the patient with Tylenol (acetaminophen) and sometimes combine that with the drug Reglan (metoclopramide),” she says. “Metoclopramide is typically used as an anti-vomiting medication, but it actually has benefits for stopping the migraine attack itself, and that, in combination with the acetaminophen, can be really helpful,” she says. “Sometimes I’ll even add a little bit of Benadryl (diphenhydramine) in there, too, because that can help with providing some sleepiness or sedation. The idea is that the combination can help someone take a nap, and when she wakes up, the migraine attack will hopefully be done,” says Starling.
Lidocaine Nerve Blocks
One of the other therapies that we have pretty good evidence for is lidocaine, says Starling. “The FDA no longer uses pregnancy risk letter categories to indicate a drug’s safety during pregnancy, but when they did, lidocaine was a category B medication, so it was considered to have some data to show some safety in pregnancy,” she says. According to the American Migraine Foundation, nerve blocks, in which an anesthetic and sometimes a steroid are injected near the nerve to block pain, are considered a safe migraine intervention for pregnant women. Lidocaine injections at the base of the skull — called an occipital nerve block — can be really helpful in stopping a migraine attack, says Starling. “This can help with base of the skull or neck pain, as well as with the pain that can radiate from the back of the head but settles in behind the eyes,” she says. Those are all common locations for pain and migraine, adds Starling. “Sometimes I’ll use these injections once every month or even as frequently as once every week for my patients who are pregnant. It can often work as a preventive treatment for them or be used to break an attack that might be ongoing,” she says.
Triptans
Triptans are one of the most commonly prescribed first-line medications that are specifically for the treatment of migraine attacks, says Starling. “If you read the package labeling, it will tell you that the drug is not something that should be used in pregnancy and that it’s not been studied in the setting of pregnancy,” she says. However, some triptans have been around for quite some time and have a considerable amount of registry data for being used during pregnancy, says Starling. Pregnancy exposure registries are studies that collect health information on exposure to medical products such as drugs and vaccines during pregnancy. “There is a good amount of evidence for the safety of Imitrex (sumatriptan), Maxalt (rizatriptan), and Amerge (naratriptan). For my patients who didn’t get relief from Tylenol and Benadryl and lidocaine, I will sometimes use one of these triptan medications for them,” says Starling.
4. What Medications Should I Avoid When I’m Pregnant?
Starling recommends against taking NSAIDs such as ibuprofen and naproxen during pregnancy. “That’s because in the first trimester, these drugs are linked to an increased risk of spontaneous abortions, and in the third trimester, there are concerns about fetal kidney issues, and other issues with the fetus,” she says. A study published in 2018 in the American Journal of Obstetrics and Gynecology found that NSAID use in women around conception was associated with an increased risk of miscarriage, especially in women with a lower body mass index (BMI). The FDA issued a safety warning in 2020 that recommends avoiding NSAIDs in pregnancy at 20 weeks or later because they can result in low amniotic fluid and may cause rare kidney problems in unborn babies.
5. What if My Migraine Attacks Get Worse During Pregnancy?
If a woman develops migraine for the first time during pregnancy, or if there’s an increase in migraine symptoms during pregnancy, those symptoms should be taken seriously, according to the American Migraine Foundation. Research presented at the 2015 International Headache Congress suggested that women who had acute severe migraine during pregnancy are at increased risk for adverse pregnancy outcomes. In the study, more than half of the women (49 out of 90) experienced adverse outcomes, which included preterm delivery, preeclampsia (a potentially life-threatening disorder of pregnancy characterized by high blood pressure), and low birth weight. The investigators found no association between the medication the women were taking for migraine and their pregnancy outcomes. It’s important for all pregnant women with migraine to discuss disease management with the healthcare provider who treats their migraine, especially those women who have worsening symptoms of migraine during pregnancy.
6. What Lifestyle Changes Can I Make While I’m Pregnant to Improve Migraine?
Lifestyle measures and behavioral treatment options are important for everyone with migraine, but even more so if you’re pregnant, “because we want to avoid medications as much as possible,” says Starling. “One thing I always discuss with people are the ‘SEEDS for success’ in migraine management, which is a mnemonic that reminds people of things they can do to improve migraine,” she says.
S stands for good sleep hygiene. That means going to sleep around the same time and waking up around the same time every day, says Starling.E is exercising, and she recommends about 20 minutes of aerobic exercise at least three days a week.E stands for eating regular meals, so not fasting or skipping meals, says Starling. “This is really important: Try to eat multiple small meals throughout the day.”D is short for dehydration, or preventing dehydration, by drinking lots of water throughout the day, says Starling.S stands for stress response or stress management. “Not stress reduction necessarily, but more managing the way that you respond to stress,” she says.
“There are also some behavioral treatment options that have proven to be beneficial in evidence-based, randomized, controlled trials. These include biofeedback training, cognitive behavioral therapy training, mindfulness, and relaxation techniques,” says Starling. These therapies can be helpful for the treatment of migraine in all settings, but they should definitely be given extra consideration for use in pregnancy since they are all safe, drug-free options, she says.
7. Who Can Help Me Manage Migraine During Pregnancy?
In addition to treating people with migraine, Starling lives with the disease of migraine. “I’ve gone through multiple pregnancies and have two children, and I was able to figure it out and manage migraine in collaboration with my healthcare professional. I know it can be scary for patients, but it’s totally doable,” she says. Try to channel those feelings into being proactive in how you will manage your migraine during pregnancy, says Starling. “I always encourage patients to find a healthcare professional, whether it be your primary care doctor, your neurologist, or your headache specialist, who will collaborate with your ob-gyn to figure out how best to manage your migraine during pregnancy,” she says. “Pregnancy is hard enough for many different reasons, and I think that if we can manage migraine better, it makes it so much easier,” she adds.
