Migraine management during pregnancy requires thoughtful planning and individualized care. Amaal J. Starling, MD, FAAN, FAHS, reviews evidence-based acute and preventive strategies, including lifestyle interventions and pharmacologic and nonpharmacologic options, and outlines shared decision-making principles that should help guide treatment in this setting.

I let all of my female patients who are in their reproductive years know that it is important that we have a plan for their migraine, and I assure them that we can manage it in the setting of pregnancy. From a migraine management perspective, we have 2 considerations: the preventive and acute treatment of migraine. Migraine prevention during pregnancy should include discussions on lifestyle modifications that can raise the threshold for having a migraine attack. I always talk to my patients about the “SEEDS for success,” which include having good Sleep hygiene, Exercising consistently, Eating regular and healthy meals with adequate hydration, using a headache Diary to assess and monitor symptoms and treatment, and appropriately managing Stress. Optimizing these measures raises the threshold so that it is less likely for a patient to have a migraine attack.

Using evidence-based nonmedication approaches such as biofeedback, cognitive behavioral therapy, and progressive muscle relaxation is also something that we talk about with all patients with migraine, especially in the setting of pregnancy. Additionally, there are several noninvasive neuromodulation devices that may be considered for prevention and as-needed treatment in the setting of pregnancy.

Certain medications can also be used during pregnancy. From an acute treatment perspective for migraine, the first-line therapy is acetaminophen. I often combine acetaminophen with metoclopramide, which can be helpful for both nausea and the migraine attack itself. However, for some women, that may not be enough.

Triptan medications, particularly sumatriptan, have evidence for safety when migraine-specific acute treatment is indicated in the setting of pregnancy. Observational studies and registries of women using sumatriptan during pregnancy demonstrate that there is not an increased risk of fetal and/or maternal complications compared with women who do not use sumatriptan. We will sometimes combine sumatriptan with metoclopramide or ondansetron if the patient’s nausea is severe. We can also consider the combination of sumatriptan, metoclopramide, and diphenhydramine, which can very effectively treat more severe migraine attacks, even in the setting of pregnancy.

The preventive treatment of migraine during pregnancy really needs to be individualized based on migraine frequency prior to pregnancy. If patients have a history of 4 or more headache days per month with associated disability and indications for prevention, we want to make sure that they can safely continue preventive therapy. Supplements such as magnesium, vitamin B₂, and coenzyme Q10 can be used during pregnancy, so I typically will continue those. β-blocker medications such as propranolol or metoprolol are also good migraine preventive treatment options, especially when there is hypertension present. Moreover, low-dose amitriptyline can be an option for migraine prevention during pregnancy. In patients who are pregnant, we want to avoid topiramate and valproic acid, which are contraindicated due to established teratogenicity. CGRP-targeted medications are also generally avoided in patients who are pregnant because they currently do not have safety evidence in the setting of pregnancy. Finally, onabotulinumtoxinA injections, which can be used for the preventive treatment of chronic migraine, have some registry data suggesting no increased risk of maternal or fetal complications in the setting of pregnancy. I have a conversation with my patients who are on onabotulinumtoxinA injections to decide whether we are going to continue use during pregnancy.

What is most important during pregnancy is counseling around options for prevention and acute treatment and having very frank discussions about the potential risks and available data. This enables us to engage in shared decision making regarding what to do for the preventive and acute treatment of migraine during and after pregnancy.