What to Expect When You’re Expecting: The Migraine Edition

By: Julie Bucklan, DO • Posted on December 08, 2020

What to Expect When You’re Expecting: The Migraine Edition

Headache and Pregnancy

More than half of women with migraine report improvement during pregnancy. What about the other half? Most headaches that occur during pregnancy are migraines, but one should see their doctor to help evaluate if a secondary cause is possible. The hypercoagulable state of pregnancy increases the risk of secondary headache disorders. This risk remains until about 6-weeks post-partum, as the body undergoes rapid hormonal changes and returns to its non-pregnant state.

Red flag signs

  1. New-onset headaches
  2. Sudden increased headache severity
  3. Pregnancy-related hypertensive disorders (example: preeclampsia)
  4. Headaches with new neurologic deficits (difficulty speaking, double vision, inability to move part of your body)

Is imaging safe?

For those who require additional testing, imaging does not put the mother at risk. CT poses minimal risk to the fetus, but a MRI is considered to be the safest choice for both fetus and mom. Gadolinium Contrast dye (used with MRI) can cross the placenta and may adversely affect the fetus, so this should only be done if necessary. Iodinated contrast dye (used with CT) should absolutely be avoided as this can affect thyroid function in the fetus.

Treatment for Migraines During Pregnancy

There are many available treatment options for migraine during pregnancy (both pharmacologic and non-pharmacologic). It’s important to bear in mind that severe chronic pain can lead to depression, anxiety, insomnia, and high blood pressure which may prove more dangerous than using medications. Ultimately, medication risks are highest in the first trimester, so if able to delay pharmacological treatment until second trimester, that is ideal.

Pain relief vs. fetal risk

The tables below list the daily preventives and migraine rescue medicines which can be considered for use during pregnancy.

Daily Preventives

Medication Level of
Evidence for Migraine
FDA
Pregnancy Rating
Potential
Teratogenic
Risk
MemantineLimited dataBNo known risk
to fetus
CyproheptadineCBLimited studies;
no evidence of
risk to fetus
PindololCBDO NOT USE IN
1ST TRIMESTER -
risk of cardiovascular
defects, cleft lip/
palate, neural tube
defects; if administered
while giving birth
can cause neonatal
bradycardia, respiratory
depression
or hypoglycemia
Magnesium oxideBD*Previously deemed
the only safe
migraine supplement
in pregnancy,
FDA pregnancy
rating changed
in 2013 based
on trials of IV
magnesium sulfate
given >5-7 days
leading to cases
of skleletal abnormalities/
bone fractures
in neonates

Migraine Rescue Medications

MedicationLevel of
Evidence for Migraine
FDA
Pregnancy Rating
Potential
Teratogenic
Risk
MetoclopramideBBNo adequate
studies; no
evidence of risk
to fetus
DiphenhydramineCB
OndansetronUBConsidered
safe for nausea.
Does not help
pain of migraine
SumatriptanACThere is a registry
of infants whose
mothers used sumatriptan,
and no harm
was found with
its use acutely
to treat migraine. Risk
of post-partum hemorrhage
and spontaneous
abortion
AcetaminophenAB (oral); C (IV)Use over multiple
trimesters and/or
for >20 weeks
during pregnancy
can increase
risk of pediatric
development
of ADHD or
wheezing,
but this is debated
Lidocaine nerve blockABNo known
teratogenic effect

* = It is unclear if the “D” rating should be generalized to oral magnesium supplements and magnesium oxide is still commonly used.

AAN/AHS A-C guideline level of evidence:
  • A-strongest evidence to C-least strong evidence
FDA pregnancy medication ratings:
  • A – safest (controlled studies fail to demonstrate risk)
  • B – animal studies have failed to show risk, no adequate studies in humans
  • C – animal studies have shown no adverse effect on the fetus, no adequate human studies

Before taking any medication, always be sure to check in with your physician first.

Be Strong, Be Healthy, Be in Charge!

-Julie Bucklan, DO

To schedule an appointment with Dr. Julie Bucklan, please call 216-636-5860. Dr. Bucklan is currently seeing patients both virtually and in-person. She sees patients in-person at Cleveland Clinic Twinsburg on Monday, at Cleveland Clinic Main Campus Tuesday-Thursday, and at Mellen Center for Multiple Sclerosis on Friday.

Julie Bucklan, DO is an associate staff at the Neurological Institute at Cleveland Clinic. She has been with the Cleveland Clinic since 2014, during which time she completed her residency and headache fellowship at CCF before staying on as a staff physician. She welcomes all headache patients, but her specialty interest is in migraine and the female reproductive cycle (from menstruation to menopause). She also serves as an assistant professor of neurology for Cleveland Clinic Lerner College of Medicine and Case Western Reserve College of Medicine.


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