Migraine Prophylaxis in Pregnancy

1) Most women with migraine improve during pregnancy (particularly migraine without aura). A need for prophylaxis does not commonly arise

2) Due to hormonal changes, migraine may change to aura without headache

3) Non-drug therapies / lifestyle management should be promoted (please see Migraine Trust: https://migrainetrust.org/)

Prophylaxis

• No prophylactic medication is 100% safe in pregnancy
  • A need for prophylaxis does not commonly arise and time may be all that is needed
  • Consider prophylaxis only when risk of uncontrolled migraine to mother’s health outweighs potential adverse risk
  • SIGN do not recommend a specific medication in pregnancy but Propranolol generally considered 1^st followed by Amitriptyline (keeping to lowest possible dose)

Acute Treatment

• Ibuprofen can be used until gestational week 28. After 28 weeks of gestation, repeated use of ibuprofen should be avoided
• Paracetamol may be used in all trimesters of pregnancy although routine use should be avoided.
• Where treatment with paracetamol or ibuprofen fail, sumatriptan, in all stages of pregnancy can be considered. None of the triptans however are classed as non-teratogenic.

Lactation 

• For acute treatment consider Paracetamol, Ibuprofen or Sumatriptan
• For preventative treatment Propranolol 1^st Amitriptyline may be considered but caution in premature infants

Further information

For more information on the management of migraine in pregnancy and following child-birth, please see National Headache Pathway - Migraine During Pregnancy and After Childbirth