Pregnancy and Lactation – Migraine Management

Along with the excitement of a possible pregnancy, migraineurs often experience a feeling of dread, wondering which headache medications need to be discontinued and how to manage expected migraines without their usual treatment regimen. This anxiety extends from the time when pregnancy is possible but not established, during the 9 months of actual pregnancy and beyond, when breastfeeding passes on mother’s milk to the newborn infant. The good news is that most women notice their migraines either go away or greatly improve in the 2nd and 3rd trimesters of pregnancy. At least 4-8% of women do not have this lucky break, and for them managing migraines can be particularly challenging. After delivery, most women quickly return to their pre-pregnancy migraine pattern. While nursing, many medications remain off the safe list because of potential problems passed through the mother’s milk, but treatment options do improve. Perhaps, the most difficult time is when a woman is planning pregnancy and it is unknown whether she is actually pregnant. Unfortunately, to avoid fetal exposure to potentially harmful medications, it is necessary to stop most migraine preventive medications and avoid the use of typical prescribed and over-the-counter as-needed medications previously used for headache. During normal menstrual periods, using these acute medications may be considered safe, as flow signals that a pregnancy has not actually taken place. At other times, it must be presumed a woman is pregnant if she is not using contraception. Migraine preventive medications do not generally permit the luxury of stopping and starting abruptly, and need to be tapered when planning a pregnancy, or as soon as possible in the event of an unplanned pregnancy. Many medications are best removed by a gentle wean, although others can be stopped quickly, particularly in situations in which an unplanned pregnancy is confirmed. Any confirmed pregnancy while taking medications should result in a phone call to the headache treatment provider’s office for immediate advice, followed by an office visit for migraine management counselling while pregnant. Grouping medications into three broad categories, there are those known to cause fetal harm in humans or animals, those for which no harm has been found to date, and those that have been studied extensively through testing and/or patient and infant follow-up, with no increase in fetal or infant defects. Before deciding if a medication is needed to help prevent or treat migraines in pregnancy, it may be best to consider the safest interventions, which are lifestyle changes likely to reduce the frequency and severity of migraine. These include eating regular, healthy meals, adequate sleep, and at least one half hour of exercise (walking is fine) per day. Behavioral treatment for stress reduction such as relaxation training, biofeedback, and yoga may be helpful. Options are limited in prescription preventive medications, because of the need to avoid any medication that has shown some problem in animals or fetuses. Memantine (brand name Namenda, Actavis, New York, USA) is one of the few preventives not found to cause harm in developing fetuses. It is a drug typically used to treat dementia, but it has also been found to be helpful in some studies of migraine prevention. It works by blocking glutamate, a chemical associated with increased migraine pain and frequency. Another preventive medication used in pregnancy is cyproheptadine, an antihistamine. It has been used for decades for migraine prevention, is considered safe in pregnancy, and is inexpensive. However, the major drawbacks include weight gain and fatigue, so this medication has limited appeal in those who are not pregnant. Taking cyproheptadine at night and at the lowest effective dosage can be helpful. It is not to be used in breastfeeding, though. Magnesium is frequently cited as a safe migraine preventive medication in pregnancy. Unfortunately, there have been recent findings showing intravenous high-dose magnesium can be associated with bone abnormalities in the fetus. Since it is not known at what dosage these bone abnormalities may occur, or if they happen when magnesium is taken by mouth, magnesium is no longer recommended as a daily preventive medication in pregnancy. Acupuncture is controversial with regards to effectiveness for migraine. Clear proof of effectiveness has not been found, and when used in pregnancy there can be an increased risk of miscarriage depending on the location of needle placement. Licensed massage can be helpful in the hands of a knowledgeable practitioner familiar with pregnancy precautions. When a pregnant woman does get a migraine, there are as-needed medications that are considered likely to be safe. These include metoclopramide, diphenhydramine, caffeine, cyproheptadine, and acetaminophen. However, even acetaminophen, often felt to be the safest headache medication in pregnancy, has recently shown some possibility of risk. A large Danish study found an increased frequency of behavioral disorders such as hyperactivity in children whose mothers took acetaminophen while pregnant. Although this study is new and further investigation is needed, it serves as a caution against taking acetaminophen unless it is necessary, and not taking it too frequently in any case when pregnant. Nerve block injections using lidocaine, which is similar to the medication used at the dentist’s office for numbing the gums, represent another option for difficult-ro-treat migraines in pregnancy. Lidocaine has not been found to cause birth defects or problems in pregnancy, and is injected using a needle to block nerve pain in the head and scalp. It is low risk, but as with any injection, there is the risk of side effects coming from spreading of the medication resulting in numbing of unintended areas, bleeding, and infection. Headache: The Journal of Head and Face Pain © 2015 American Headache Society Published by John Wiley & Sons, Inc. doi: 10.1111/head.12540