Contemporary management of migrainous disorders in pregnancy
Purpose of review: Migraine is a frequent event among women of reproductive age. It is difficult to predict the course and severity of disease that migraineurs will endure during pregnancy. Treatment is often compromised during pregnancy because of concerns regarding pharmacotherapy and fetal well being.
Recent findings: The majority of women with migraine during pregnancy will not require ongoing pharmacotherapy or prophylaxis. Nonpharmacologic strategies should be the first-line treatment of migraines. For severe migraines, recent cohort studies documenting the use of triptans for treatment during pregnancy have shown no increase in adverse pregnancy and fetal outcomes above the average rate. High-dose valproate is the only antiepileptic drug available for migraine prophylaxis that has been shown to cause long-term cognitive effects in infants exposed during gestation. Congenital syndromes have been described for most of the older antiepileptic drugs but less so for many of the newer drugs. These newer medications appear to have improved safety profiles for use in pregnancy but there is still information lacking from larger patient cohorts and longitudinal studies of neurodevelopmental outcomes. There is also evidence to support use of beta-blockers and calcium-channel blockers for migraine prevention during pregnancy.
Summary: For those patients who develop debilitating migraine or whose migraines interfere with activities of daily living, there are several options for treatment and headache prevention that have a low likelihood of compromising fetal well being.
###
Introduction
Migraine headaches are periodic pain attacks on one or both sides of the head. Nausea, vomiting, photophobia, phonophobia, dizziness, blurry vision, cognitive disturbances, and other symptoms may accompany them. Some migraines do not include headache, and migraines may or may not be preceded by an aura [1].
Epidemiology
Approximately 10% of pregnant women will complain of headache before or during pregnancy. Most patients with chronic headaches have been diagnosed prior to pregnancy [3]. Occasionally patients develop new-onset headache with pregnancy that requires a diagnostic workup. Many patients will require some form of treatment during pregnancy. Therapy of migraine focuses on both prevention and treatment of symptoms. Pregnancy complicates management by limiting the use of medications that could potentially compromise fetal development, well being and long-term neurodevelopment. This article will focus on the quality of evidence supporting those therapies available for both headache treatment and prevention. We will also address the safety of pharmacotherapy during pregnancy.
Classification
Headaches during pregnancy may be primary or secondary. Primary headaches such as migraine and tension-type headaches often develop during the first half of pregnancy and improve during the later stages of pregnancy. Secondary headaches are most often due to vascular, tumor or infectious pathology and can appear at any time during pregnancy unless associated with hypertension, which most often develops in the third trimester.