When Should You Worry?
If women who experience migraines experience a change in headache pattern during pregnancy, Dr. Hayes says they require evaluation to exclude other causes of headache, such as the following:
- Preeclampsia if after 20 weeks of gestation: Characterized by high blood pressure, elevated urine protein, and sometimes rapid increase in swelling and sometimes accompanied by new headache, visual changes such as blurring or spots, right upper abdominal pain
- Pseudotomor cerebri: Increased pressure inside the brain
- Intracerebral hemorrhage: Increased blood volume in pregnancy may contribute to rupture of preexisting arteriorvenous malformations or aneurysms
- Infectious causes of headache: Such as meningitis or sinusitis
- Cerebral venous thrombosis: Blood clot in a vein around the brain
"Pregnant women are at increased risk of all of these other causes of headache, so anyone with 'worst headache of her life' or a significant change in headaches needs prompt evaluation," Dr. Hayes says.
Liane Worthington, who lives near Scranton, Pennsylvania, had never had a migraine until her first pregnancy. She was young and fairly healthy, but at 32 weeks pregnant, she developed a strange headache that became a migraine complete with vomiting, dizziness, and incoherence. "I developed toxemia, a full-blown case (complete with seizure a day later)," Worthington says. There were no indications of the condition until she got her migraine, when her blood pressure soared and triggered the headache. She had to deliver her daughter seven weeks early by emergency C-section, but they both recovered quickly and had no complications afterwards. In fact, Worthington went on to have two more kids without complications.
A change in headache pattern was also a clue for Natasha Baker of Dayton, Ohio. Baker has had menstrual migraines since she was 12, but pregnancy actually resulted in more tolerable migraines. In month 4, with both of her pregnancies, the migraines slowed down. "However, I started getting them again in the last week of the pregnancy," Baker says. "They were actually a trigger to my doctor that it was time to schedule the C-section. At that point, I had elevated blood pressure and increased swelling—all symptoms of preeclampsia."
"Standard medications used for migraines such as triptans, anticonvulsants, and calcium-channel blockers are not suggested as treatments during pregnancy because of the possible risk to the fetus," Dr. Derman says. "Under no circumstances should patients be started on a daily scheduled medication during pregnancy."
It is suggested that women who are taking preventive medications for migraine discuss options with their physician prior to pregnancy. Dr. Hayes says that if a daily preventive medication is needed, amitriptyline (Elavil) at low doses has a long track record in pregnancy, as do beta blockers. Beta blockers such as metoprolol, atenolol, and propranolol have not been associated with fetal malformations but may contribute to decreased growth in the fetus, so close monitoring of fetal growth with ultrasound is recommended, she says.
Baby aspirin, 81 milligrams daily, may help prevent migraine headaches and is reasonable during pregnancy, Dr. Hayes says. She also recommends acetaminophen 1,000 milligrams by mouth plus metoclopramide (Reglan, a prescription anti-nausea medication) 10 milligrams by mouth, and a caffeine-containing drink at the onset of a migraine headache, then rest in a quiet, dark room. This and other anti-nausea medications are "commonly used for acute migraine treatment in emergency departments; these medications are reasonable during pregnancy," Dr. Hayes says. "No published studies have evaluated the effectiveness of anti-nausea medications for migraine treatment in pregnant women."
For acute headache treatment, non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen are not recommended during pregnancy, particularly beyond the second trimester, due to concerns for early closure of the ductus arteriosus (important for fetal heart-lung flow), low amniotic fluid levels, and effects on fetal kidneys, Dr. Hayes says. The same goes for full-sized aspirin.
Of course, there's always non-pharmacological therapy. "There's good evidence that supports the use of relaxation training, biofeedback training, and cognitive behavioral therapy in the treatment of migraine," says Dr. Brian Grosberg, director of the Impatient Headache Program at Montefiore Headache Center in the Bronx, New York. "Non-pharmacological behavioral management of headache should be recommended as a standard adjunctive treatment for all women with migraine that are pregnant or planning on becoming pregnant," Dr. Grosberg says. "It is best if these techniques can be taught and used by the patient before pregnancy commences."
Dr. Hayes and her colleagues are evaluating effectiveness of acute migraine treatments in pregnant women. "Magnesium sulfate has shown some promise as an alternate headache treatment," she says. "This is appealing as it has been used in obstetrics for decades, in an attempt to delay labor, and also to prevent seizures in women with preeclampsia."