References:
Planning Pregnancy While Managing Migraine
American Council for Headache Education http://www.achenet.org
Many women with headaches worry about what will happen to their headaches once they are pregnant. Actually, the "periconceptional" period -when someone is trying to get pregnant but is not sure if they are or are not pregnant- can be a challenging time. Most women do not realize that they are pregnant until a week or so after they have missed a period. Urine pregnancy tests, although good and getting better, may not be positive that early. A migraine patient is concerned that medications taken early in pregnancy to treat headache could be harmful to the developing fetus.
Many commonly used headache medications have unknown effects during pregnancy. However, to minimize potential problems, many headache experts recommend that women with headache pay special attention when planning their pregnancies. For example, it helps to minimize the number of months where patients have to wonder whether or not they are pregnant. Making an effort to conceive quickly can do this. Couples may use an ovulation predictor kit sold in drugstores to monitor ovulation and concentrate intercourse to that period. Doctors disagree on how often patients should have intercourse when trying to become pregnant, but some suggest once a day is optimal.
Many headache experts recommend tapering off daily preventive medications if planning to get pregnant. Generally patients do not need to avoid their preventive medications for several months before attempting to conceive; but about a week or so is fine (check with your doctor to determine specific treatment strategy changes). Some women with very severe headache problems are not able to taper off their daily medications. In that case, discuss the potential risks of these medications with the doctor before becoming pregnant. While some commonly used preventive therapies (beta-blockers and tricyclics) have a reassuring track record when used in pregnancy, others (especially sodium valproate or Depakote®) are known to cause birth defects. Many birth defects occur early in pregnancy, often during the first three months, when major organ systems are forming. Therefore, waiting until after conceiving to make decisions about preventive medication for migraine is not recommended. For a review of medications and their use in pregnancy and menstrual migraine, see the Table below:
| Fetal Risk | Breast Feeding | |
| Analgesics | ||
| Simple Analgesics | ||
| Aspirin | C* | Caution |
| Acetaminophen | B* | Compatible |
| Caffeine | B | Compatible |
| * D if used during 3rd trimester | ||
| Narcotics | ||
| Butorphanol | B** | Compatible |
| Codeine | C** | Compatible |
| Hydromorphone | B** | Compatible |
| Meperidine | C** | Compatible |
| Methadone | B** | Compatible |
| Morphine | B** | Compatible |
| Propoxyphene | C** | Compatible |
| ** D if prolonged or at term | ||
| Nonsteroidal Anti-inflammatory Drugs (NSAIDs) | ||
| NSAIDs | ||
| Fenoprofen | B* | Compatible |
| Ibuprofen | B* | Compatible |
| Indomethacine | B* | Compatible |
| Meclofenamate | B* | Compatible |
| Naproxen | B* | Compatible |
| Sulindac | B* | Compatible |
| Tolmetin | B* | Compatible |
| * D if used during 3rd trimester | ||
| Sedatives/Hypnotics | ||
| Barbituates | ||
| Butalbital | C | Caution (sedation) |
| Phenobarbital | D | Caution (sedation) |
| Benzodiazepams | ||
| Chlordiazepoxide | D | Concern*** |
| Diazepam | D | Concern |
| Lorazepam | D | Concern |
| Clonazepam | C | Concern |
| *** effects unknown | ||
| Neuroleptics/Antiemetics | ||
| Antihistamines | ||
| Cyclizine (Marezine) | B | NA |
| Cyproheptadine | B | Contraindicated |
| Dimenhydrinate (Dramamine) | B | NA |
| Meclizine (Antivert) | B | NA |
| Other | ||
| Emetrol | B | Compatible |
| Doxylamine succinate and Vitamin B6 (Bendectin) | B | NA |
| Trimethobenzamide (Tigan) | C | NA |
| Neuroleptics | ||
| Phenothiazines | C | Concern |
| Chlorpromazine (Thorazine) | C | Concern |
| Prochlorperazine (Compazine) | C | Compatible |
| Promazine (Sparine) | C | NA |
| Haloperidol (Haldol) | C | Concern |
| Thiothixene (Navane) | C | NA |
| Metoclopramide (Reglan) | C | Concern |
| Ergots and Serotonin Agents | ||
| Ergots and Serotonin Agonists | ||
| Ergotamine | X | Contraindicated*** |
| Dihydroergotamine | X | Contraindicated |
| Methylergonovine maleate | C | Caution |
| Methysergide | D | Caution |
| Naratriptan | C | Caution |
| Rizatriptan | C | Caution |
| Sumatriptan | C | Caution |
| Zolmitriptan | C | Caution |
| *** Vomiting, diarrhea, convulsions | ||
| Antihypertensives | ||
| Beta-blockers | ||
| Atenolol | C | Compatible |
| Metoprolol | B | Compatible |
| Nadolol | C | Compatible |
| Propranolol | C | Compatible |
| Timolol | C | Compatible |
| Adrenergic Blocker | ||
| Clonidine | C | Compatible |
| Calcium Channel Blocker | ||
| Diltiazem | C | Compatible |
| Nifedipine | C | Compatible |
| Verapamil | C | Compatible |
| Antidepressants | ||
| Amitriptyline | D | Concern |
| Amoxapine | C | Concern |
| Bupropion | B | Concern |
| Desipramine | C | Concern |
| Doxepin | C | Concern |
| Fluoxetine | B | Concern |
| Imipramine | D | Concern |
| Nefazodone | C | Concern |
| Nortriptypline | D | Concern |
| Sertraline | C | Concern |
| Paroxetine | C | Concern |
| Phenelzine | C | Concern |
| Protriptyline | C | Concern |
| Venlafaxine | C | Concern |
| Other Drugs | ||
| Anticonvulsants | ||
| Carbamazapine | C | Compatible |
| Gabapentin | C | ? |
| Lamotrigine | C | ? |
| Phenobarbital | D | Compatible |
| Phenytoin | D | Compatible |
| Topiramate | D | ? |
| Valproic acid | D | Compatible |
| Corticosteroids | ||
| Cortisone | D | Compatible |
| Dexamethasone | C | Compatible |
| Prednisone | B | Compatible |
| Other | ||
| Bromocriptine | C | Contraindicated* |
| Diphenoxylate | C | Compatible |
| Lidocaine | C | NA |
| Lithium | C | Contraindicated** |
| Paregoric | B*** | Compatible |
| * Suppresses lactation | ||
| ** 1/3 to 1/2 therapeutic blood levels in infants | ||
| *** D if prolonged use of 3rd trimester | ||
Drug Labeling in Pregnancy
The Food and Drug Administration lists five categories of labeling for drug use in pregnancy:
| Category A: Controlled studies show no risk. |
Adequate, well-controlled studies in pregnant women fail to demonstrate a risk to the fetus. |
| Category B: No evidence of risk in humans. |
Either animal-reproduction studies have not demonstrated a fetal risk but there are no controlled studies in pregnant women, or animal-reproduction studies have shown an adverse effect (other than a decrease in fertility) that was not confirmed in controlled studies in women. |
| Category C: Risk cannot be ruled out. |
Either studies in animals have revealed adverse effects on the fetus (teratogenic or embryocidal or other) and there are no controlled studies in woman, or studies in women and animals are not available. Drugs should be given only if the potential benefit justifies the potential risk to the fetus. |
| Category D: Positive evidence of risk. |
There is positive evidence of human fetal risk, but the benefits from use in pregnant women may be acceptable despite the risk. |
| Category X: Contraindicated in pregnancy. |
Studies in animals or human beings have demonstrated fetal abnormalities, or there is evidence of fetal risk based on human experience, or both, and the risk of the use of the drug in pregnant women clearly outweighs any possible benefit. |
If a headache sufferer becomes pregnant (approximately 44% of all pregnancies resulting in live births are unintended)
and has been taking medication, they should not panic! Although it is difficult to say with certainty, it is unlikely that commonly used headache medications will cause major problems. There are many sources of information about the risks of medications when taken during pregnancy. Manufacturers include information in the package insert, and many agencies have telephone hot lines, and other information is available in the published literature.
General "headache hygiene" is crucial for women who have headaches and are trying to get pregnant. Many physicians recommend that women continue their current therapy or even start nonpharmacological headache treatments for headache. Other nonpharmacological ways to improve headache management include:
Migraine During Pregnancy
Treatment of Migraine During Pregnancy
Most women are highly motivated to avoid using unnecessary medications during pregnancy. If at all possible, it is best to minimize medication during the important first trimester of pregnancy, when many organ systems are developing in the fetus. Drugs or environmental factors that cause birth defects or problems usually cause that particular problem only if they are present during the stage at which the organ system is developing. If the fetus is exposed to these factors before or after the development of the organ system they affect, there is generally no effect. Since so much development takes place during the first trimester, it is best to be off medication at that time, if at all possible.
Growth and development of the fetus continues throughout the second and third trimesters. Many things can still negatively affect the central nervous system (brain and spinal cord) during this time. For this reason, most women and their doctors try hard to minimize medication use throughout pregnancy. There are times, however, where the benefits of medication treatment might outweigh the potential risks. For example, if a woman is so ill from headaches that she is vomiting frequently, dehydrated, losing weight and unable to function, most people would accept that headache treatment might be necessary despite potential risks, since the pregnancy itself can be threatened.
As a general rule, use of medications should be restricted during pregnancy to avoid harming the fetus. Some medications may be associated with birth defects, embryo toxicity, delayed fetal growth, interference with uterine contractions during labor, or direct effects on the newborn baby. For this reason, nonpharmacological therapies are often recommended during pregnancy.
Pharmacological (Medication) Treatments
Proving which drugs are "safe" during pregnancy is not an easy matter. For one thing, since most pregnant women avoid using medication, it can take a long time to collect information about the effects of drugs in pregnancy. Furthermore, no drug manufacturer will study use of a drug in pregnant women because it is ethically impossible to justify doing randomized, controlled clinical research on pregnant women. Another problem is figuring out if reported adverse events were actually attributed to the medication or might they have happened anyway. Studies show that 1% to 2% of babies will have some type of malformation or congenital problem at birth, even when they are not exposed to drugs or other problem-causing substances.
Long-term experience with some types of medications causes us to believe that they are relatively safe for use during pregnancy. Even these drugs, though, need to be used in moderation and under careful medical supervision. Headache medications that most physicians feel can be used in pregnancy include:
Triptans, Ergotamine, and Dihydroergotamine: The long-term effect of migraine medications that cause blood vessel constriction (narrowing) is not clearly established. These drugs (e.g., triptans, ergotamine, dihydroergotamine) should be monitored closely or even avoided during pregnancy. However, many companies that make these medications support pregnancy registries. Women who take medications such as triptans can enroll in these registries and provide valuable information regarding the safety of these medications for use during pregnancy.
NSAIDS and Combination Analgesics: For pregnant patients that need medication for their migraine attack, acetaminophen is considered safe and is the drug of choice for mild-to-moderate headache. Codeine occasionally may be added to increase the efficacy of acetaminophen when treating more severe migraine attacks. Caffeine may help in the acute treatment of migraine, either alone or in combination with other measures. Moderate (less than 300 mg per day) caffeine use is not considered harmful to the fetus. Aspirin and NSAIDs may increase the risk of bleeding in the mother and fetus, and when used late in pregnancy these agents may interfere with labor. For these reasons, their use is generally restricted during pregnancy.
Narcotics: Selected narcotic medications are considered relatively safe for use during pregnancy (caution should be taken to avoid overuse and address dependency concerns).
Treatment of Nausea and Vomiting: Medications to help with nausea and vomiting may also be needed. Emetrol® which acts on the wall of the gastrointestinal tract, and trimethobenzamide (Tigan®) are felt to be safe agents for treatment of nausea and vomiting. If headache or nausea and vomiting are severe and do not respond to conservative management, patients may require hospitalization in order to receive intravenous fluids and treatment with narcotics.
Preventative medications that have been used safely during pregnancy include selected beta-blockers, tricyclic antidepressants, and calcium channel blockers, although these should be used only when absolutely necessary. Patients should always discuss the use of all medications with their obstetrician, especially if there is a different physician for treatment of migraine or for headache management in general.
Non-Pharmacological Techniques
Nonpharmacological techniques can help for almost every headache patient, and their use should be particularly stressed during pregnancy. Some nonpharmacological measures can be started at home and require no formal treatment plan. These include:
If headaches continue to be especially troublesome, consider reducing work hours or other responsibilities. Many physicians would rather write a letter to a patient's employer asking for reduced work hours than prescribe medication for headache control.
Frequency and Cause of Postpartum Migraine
Headache within the first week after delivering (first postpartum week) occurs in over one third of all women, but in nearly two thirds of women with migraine. The postpartum headache is often less severe than one's typical migraine headache.
During the final trimester of pregnancy, estrogen levels increase to 100 times what they were prior to pregnancy. After delivery of the baby, estrogen levels fall quickly. This rapid change in estrogen levels may trigger an attack in patients with a predisposition to migraine. Although estrogen levels are higher during pregnancy, the rapid decline in estrogen at the time of birth resembles the withdrawal of estrogen that occurs monthly before the menstrual period.
Treatment of Postpartum Migraine
Safe treatment of migraine after pregnancy depends on whether a woman is breastfeeding the infant. Medications that should be avoided include bromocriptine, ergotamine, cyproheptadine, and lithium. There is very little data regarding the use of triptans while breastfeeding. Benzodiazepam (e.g, Ativan®, Valium®), barbiturates (e.g., Fioricet®, Fiorinal®, Esgic®), antidepressants (e.g., Elavil®, Pamelor®) and neuroleptics (drugs that work on the dopamine system of the brain, e.g., Risperdal®, Seroquel®) should be used cautiously. Acetaminophen is preferred over aspirin.
Managing Migraine when Breastfeeding
Breastfeeding has many advantages for the baby (and some for the mother, as well) compared with formula feeding. It would be a shame if concerns over headaches prevented women from breastfeeding. Several issues need to be considered when deciding to breastfeed while managing headaches. Importantly, there are several "tricks" that women can do that will allow them to make decisions about medication while breastfeeding.
Delaying Return of the Menstrual Cycle
If women are breastfeeding exclusively, with little or no formula supplementation, the return of the menstrual cycle probably will be delayed. For women who experience migraine with their menstrual cycle, this is a positive feature of continued breastfeeding. However, this is not true for everyone. Sleep deprivation for the mother is not uncommon after she has a new baby, and the stresses of being a new parent can cause an increase in headaches for some women. Once the baby starts eating solid food, or if the mother decreases the frequency of breastfeeding (such as if they return to work), the menstrual cycle may come back. For many women, headaches will likely return to their pre-pregnancy pattern.
Medications Excreted in Breast Milk
Unfortunately, many medications that the mother might take to help manage headache are released (excreted) into the breast milk and can be passed on to the baby. For example, sedative or narcotic medications can make the breastfeeding infant sleepy and may not be advisable. Many commonly used acute headache medications have short half-lives, which means they do not stay in the mother's system for very long. Among the triptans, for example, sumatriptan, rizatriptan, and zolmitriptan have half-lives of about 2-3 hours and should be essentially gone from the mother's system in 8 to12 hours. Some headache experts feel that pumping and discarding milk during the 8 to12 hours after using these drugs is a way to continue breastfeeding and still be able to treat headaches when they occur. However, very little is known about excretion into breast milk of most headache medications, and little is known about the dangers of exposing babies to these drugs while breastfeeding.
Pediatricians and obstetricians are aware of the concerns regarding medications that can be excreted into breast milk. Check with the pediatrician or obstetrician for specific information about using headache medication (or any medication) while breastfeeding.