Migraine and Pregnancy: What You Need To Know

Now that you’re pregnant, will your migraine attacks improve over the next nine months? For most women, the answer is yes. While the picture is mixed, here’s what you should know about migraine and pregnancy. 

During pregnancy, between 50 and 80 percent of pregnant women with migraine experience a reduction in attacks. In a 2003 study of pregnant women with migraine:

• • 47 percent reported their migraine improved or vanished during the first trimester
  • 83 percent reported migraine improving or vanishing during the second trimester
  • 87 percent reported migraine improving or vanishing in the final trimester

Is it a miracle? No, it’s probably your hormone levels. During pregnancy, estrogen increases and then remains fairly stable, and that steady level helps prevent episodic migraine attacks.

Of the 35 percent of women who don’t improve during pregnancy, many have migraine with aura. One theory is that the high estrogen-to-testosterone ratio during pregnancy lowers the threshold for a phenomenon called cortical spreading depression (CSD). CSD is an abnormal wave of electricity that moves through the brain, causing a migraine aura.

Preventing and resolving migraine attacks during pregnancy will require some adjustments to your usual strategies. You should consult your doctor to determine what works best for you.

The Pre-pregnancy Migraine Plan

Consult your physician. Preconception, it’s critical to talk with your doctor about your migraine treatment plan, whether you take over-the-counter or prescription meds, or both. Not all medicines are safe during pregnancy. Some are strictly off-limits, while other drugs can be added back after the critical first trimester. You may need to come off your preventive medicines before you conceive.

• • Botox. If you’ve been using Botox injections to reduce the frequency and severity of migraine attacks, your doctor may recommend that you try to get one last injection as close to, but prior to, conception. This injection should carry you through into the second trimester. Botox falls into the FDA’s category C of drugs, which means that studies have shown adverse effects on animal fetuses, but there are no well-controlled studies in humans. However, you and your doctor may decide that the potential benefits outweigh the risks.
  • Beta-blockers. There is no conclusive evidence that beta-blockers as a class have adverse events on fetal development. However, atenolol could be an exception, as it has been associated with low birth weight when taken in the first trimester.
  • Neuromodulation devices. This is a medicine-free preventive option to consider. These non-invasive devices (such as SpringTMS, Cefaly and Nerivio) use magnets or electrodes to influence nerves on pain pathways in the brain. They are believed to be most effective after three months of treatment. Currently, there is limited literature on these devices and their efficacy for pregnant women.
  • Warning: Certain medicines used for migraine have been determined to be NOT safe during pregnancy: Dihydroergotamine, Topamax, Depakote, ergotamines, ACE inhibitors, and ARBs.

Coordinate your care. Whatever your new migraine treatment plan, be sure to bring your obstetrician into the discussion and make sure everyone’s on the same page.

• • Pregnancy risks. Migraine is a risk factor for pregnancy-associated hypertension disorders, including preeclampsia, a potentially dangerous condition characterized mainly by high blood pressure. Make your obstetrician aware of your migraine condition to monitor you for these risks.

Optimize your health. To decrease your chances of a severe attack during pregnancy, take this pre-pregnancy period as an opportunity to build your migraine resistance. You can raise your migraine threshold by making any number of healthy lifestyle adjustments, including to your nutrition, exercise, sleep, and hydration.

Migraine Self-care During Pregnancy

Focus on Core Health. Keep your migraine resistance level high by making healthy lifestyle choices that act as protective factors for your brain.

• • Eat smart. Eat a healthy diet, in moderation, and no skipping meals — fasting is a known migraine trigger. 
  • Hydration. Drink plenty of water, as pregnant bodies need more than non-pregnant ones. Dehydration is a known migraine trigger.
  • Sleep. Healthy sleep habits are an important protection against migraine.
  • Exercise. Since your growing body can affect your balance, the safest options include walking, swimming, stationary bikes, treadmills, and elliptical machines. Yoga has been shown to be effective in preventing migraine attacks, but steer clear of hot yoga (with room temperatures over 105°F) during pregnancy.

Brain Training. Keep your stress in check with mindfulness and relaxation techniques. Consider meditation, biofeedback (which trains you to become aware of body functions and learn to control them with your mind — yes, really), and relaxation training.

Acupuncture or Acupressure. Treatment, recommended after the first trimester, can treat pregnancy-related ailments (nausea, heartburn, fatigue) as well as help prevent headaches. If you’re too squeamish about the hair-thin acupuncture needles, opt for acupressure treatment.

Physical therapy. Strengthen your neck muscles to improve general biomechanics and posture.

What to Take for a Migraine While Pregnant?

When the inevitable happens, there are safe and effective ways to deal with a migraine attack when pregnant:

Home remedies. Try ice packs, a hot shower, a heating pad, and a nap for relief.

Over-the-counter meds. If non-medical interventions for pain relief aren’t working, most doctors recommend acetaminophen (Tylenol), as they consider it the most low-risk option.

Migraine and pregnancy medication. What migraine medication is safe during pregnancy? Pharma companies don’t run clinical trials on pregnant women because of the risks involved. Ask your doctor about options that have been widely used with success, including: 

• • Sumatriptan. Of all the triptans — a migraine-stopping agent — sumatriptan has had the largest number of studied exposures among pregnant women, with no negative reports in the 30 years since triptans came on the market.
  • Nerve blocks with lidocaine injected into the muscle in the back of the neck.
  • For nausea and vomiting: Doctors may recommend Emetrol for mild nausea or doxylamine succinate, an antihistamine.
  • Meds under supervision. A severe attack may require hospitalization and IV fluids, with possible additions of prochlorperazine (used to treat nausea), opioids, or corticosteroids.

Is it normal to have migraine attacks during pregnancy? If during pregnancy you experience headaches for the first time or find your headaches are worsening, consult your doctor in case it is a signal of something other than migraine (such as meningitis, preeclampsia, or vascular complications).

Migraine And Postpartum

Unfortunately, not long after the birth of your baby, your migraine usually follows with a swift attack, often within the first week postpartum. In that time, estrogen levels drop dramatically, returning to their normal levels, and the sudden hormone withdrawal is believed to be a significant migraine trigger. Since you’ll be back on familiar migraine terrain, take advantage of support networks, friends, and family to give you the time for self-care during the early months of motherhood.