Acute treatment for migraine during pregnancy

Headache in pregnancy can be due to a range of conditions besides migraine. Differential diagnoses include pre-eclampsia, posterior reversible encephalopathy syndrome/reversible cerebral vasoconstriction syndrome, HELLP (haemolysis, elevated liver enzymes, low platelet count) syndrome, venous sinus thrombosis and pituitary apoplexy.

Migraine can get worse or improve in the first trimester, but usually improves later in pregnancy. In a quarter of females with migraine, headaches do not change in pregnancy. When managing migraine in pregnancy, it is important to ensure optimal concordance with the beneficial habits for people with migraine, to minimise the need for drugs.

During pregnancy, paracetamol is the preferred nonopioid analgesic. Avoid aspirin and NSAIDs in the first trimester and after 30 weeks. Use:

If the patient does not respond to paracetamol, sparing use of codeine is an option¹.

If the patient has nausea, metoclopramide is considered safe. In severe migraine, occasional use of sumatriptan is generally considered safe, but few data are available on other triptans.

For severe, refractory migraine, treatment options for a pregnant female include intravenous rehydration and a short course of intravenous magnesium sulfate or oral prednisolone (or prednisone). If a corticosteroid is chosen, use: