Prophylaxis for migraine during pregnancy

Ideally, a woman with frequent or severe migraine should be referred to a neurologist for expert advice before pregnancy, to optimise management and plan the approach to therapy during pregnancy.

When managing migraine in pregnancy, the first step is to ensure optimal concordance with the beneficial habits that improve migraine control.

Avoid using preventive drugs during pregnancy if possible. If a preventive drug is needed, a beta blocker or a tricyclic antidepressant is considered safest. Use preventive drugs at the lowest effective dose. If treatment can be delayed until after the first trimester, the risk of teratogenicity is less. Beta blockers can be associated with intrauterine growth retardation, and should be weaned before labour to prevent fetal bradycardia or impaired uterine contraction. Data about the safety of tricyclic antidepressants in pregnancy are conflicting. However, adverse fetal outcomes do not appear to be increased significantly overall. Consider the harms and benefits for each patient.

Supplements such as riboflavin and ubidecarenone (coenzyme Q10) are probably safe for migraine prophylaxis in pregnancy, but have not been studied as much as drugs routinely used for migraine prophylaxis. Oral magnesium has been considered safe, but in 2013 a possible link was noted between high-dose intravenous magnesium sulfate and fetal hypocalcaemia and bone abnormalities. Further studies of long-term oral magnesium therapy are needed. Short-term (less than 5 days) magnesium infusions are still considered safe for acute management.

See also acute treatment for migraine during pregnancy.