Pharmacological treatment of migraine during pregnancy and breastfeeding

Key Points

  • Migraine affects up to one in four women of reproductive age, but migraine will often improve spontaneously during pregnancy

  • Nonpharmacological approaches should always be tried as first-line treatment for migraine during pregnancy

  • Several effective acute antimigraine medications are reasonably safe to use for pregnant and breastfeeding women

  • In pregnancy, preventive drug therapy should be considered only in the most severe migraine cases

  • Periconceptional counselling is important to promote a safe and healthy pregnancy and postpartum period for the mother and child

Abstract

Migraine affects up to 25% of women of reproductive age. In the majority of these women, migraine improves progressively during pregnancy, but symptoms generally recur shortly after delivery. As suboptimally treated migraine in pregnancy could have negative consequences for both mother and fetus, the primary aim of clinicians should be to provide optimal treatment according to stage of pregnancy, while minimising possible risks related to drug therapy. Nonpharmacological approaches are always first-line treatment, and should also be used to complement any required drug treatment. Paracetamol is the preferred drug for acute treatment throughout pregnancy. If paracetamol is not sufficiently effective, sporadic use of sumatriptan can be considered. NSAIDs such as ibuprofen can also be used under certain circumstances, though their intake in the first and third trimesters is associated with specific risks and contraindications. Preventive treatment should only be considered in the most severe cases. In women contemplating pregnancy, counselling is essential to promote a safe and healthy pregnancy and postpartum period for the mother and child, and should involve a dialogue addressing maternal concerns and expectations about drug treatment. This Review summarizes current evidence of the safety of the most common antimigraine medications during pregnancy and breastfeeding, and provides treatment recommendations for use in clinical practice.

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Figure 1: Algorithm for the treatment of migraine in pregnant women.

Change history

  • 19 March 2015

    In the section discussing treatment options during pregnancy, the last sentence under the subheading 'Antidepressants' should cite reference 83, not 84. The correction has been made to the print and online versions of the article.

  • 03 April 2015

    In the section discussing treatment options during pregnancy, subheadings 'Ergot alkaloids' and 'Antidepressants' should cite reference 25, not 23. In the section discussing treatment options during breastfeeding, subheading 'Paracetamol' and 'Opioid analgesics' should cite reference 24, not 21; subheading 'Ergot alkaloids' should cite reference 19, not 24. The corrections have been made to the print and online versions of the article.

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O.S., S.A., H.N. and K.N.-H. wrote the article. All authors researched data for the article, provided substantial contribution to discussion of content and reviewed/edited manuscript before submission.

Correspondence to Olav Spigset.

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L.J.S. has received a speaker's fee from GlaxoSmithKline. The other authors declare no competing interests.

Supplementary information

Supplementary Table 1

Overview of observational studies on associations of NSAID exposure in the first trimester and miscarriage and congenital malformations (DOCX 44 kb)

Supplementary Table 2

Overview of observational studies on associations of NSAID exposure in the second and/or third trimester and other pregnancy outcomes (DOCX 31 kb)

Supplementary Table 3

Overview of observational studies on associations of triptan exposure during pregnancy and adverse pregnancy outcomes (DOCX 34 kb)

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Recommended resources on safety of medications during pregnancy and lactation (DOCX 22 kb)

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Amundsen, S., Nordeng, H., Nezvalová-Henriksen, K. et al. Pharmacological treatment of migraine during pregnancy and breastfeeding. Nat Rev Neurol 11, 209–219 (2015). https://doi.org/10.1038/nrneurol.2015.29

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