5 Questions About Migraine in Pregnancy

By: Brooklyn A. Bradley, BS; Medically edited by Dr. Deena Kuruvilla, MD

At the Westport Headache Institute, we often see patients who present with migraine during and after pregnancy. Although it is common knowledge that migraine is associated with changes in hormones, we will take a closer look at what specifically happens to migraine during pregnancy and provide some quick tips on what to watch out for. Below, we will go through our five most frequently-asked questions about pregnancy and migraine.

  1. How does migraine evolve during pregnancy?

During pregnancy, estrogen levels steadily increase, with a peak in the third trimester [1].

Rising estrogen levels during pregnancy typically correspond with an improvement in migraine. However, a steep decrease in estrogen levels occurs after delivery. In the postpartum period, nearly 40% of women experience headaches [2]. Furthermore, migraine intensity and duration often spike during the first week postpartum. Headaches are more common in women with a past history of headache, older age, increased parity (number of births (including live births and stillbirths) where pregnancies reached viable gestational age), or a shorter second stage of labor [2,3].

  1. Are migraine attacks dangerous during pregnancy?

Retrospective studies have shown that migraine does not have significant negative outcomes on pregnancy. However, untreated migraine severe enough to lead to acute care visits are associated with higher rates of preterm delivery, pre-eclampsia, and low birth weight infants. Furthermore, there are a number of secondary headache causes in pregnancy that can be dangerous, including:

  • Pre-eclampsia
  • Eclampsia
  • Posterior encephalopathy syndrome (PRES)
  • Subarachnoid hemorrhage
  • Venous sinus thrombosis
  • Arterial dissection
  • Reversible cerebral vasoconstriction syndrome

History and physical examinations are vital in distinguishing benign from life-threatening headache presentations in the postpartum period [2]. Factors taken into consideration may include time of delivery, vaginal vs. surgical delivery, complications of the pregnancy and/or delivery, use of epidural anesthesia, medication changes, substance use, family history, and chest pain. Further, physical examination findings that raise suspicion for a life-threatening secondary cause of headache include hypertension, decreased urination, swelling in the legs, visual changes, and abnormal neurological examinations [2].

It’s important to record migraine characteristics and not dismiss symptoms as a natural consequence of pregnancy. A 2015 systematic review suggested that women with migraine may have higher risks of cerebrovascular or cardiovascular complications of pregnancy, including gestational hypertension, preeclampsia, ischemic stroke, heart disease, and venous thromboembolism [4].

  1. What migraine ‘red flags’ should I watch out for during pregnancy?

Although there are many concerning symptoms that are associated with migraine, there are four ‘Red Flags’ that can signal that a migraine may be caused by a dangerous secondary cause. These red flags are:

  • Sudden or unrelenting headache
  • Lack of prior headache history
  • Hypertension
  • Neurologic abnormalities on exam
  1. What imaging studies can I take?

There are a number of imaging studies that are used to work up a migraine and rule out a dangerous secondary cause. These imaging tests include brain MRI/MRA head and neck CT/CTAs [5]. It’s important to note that all of these options have their own risks, including ionizing radiation exposure, strong magnetic fields, risk of tissue heating, and in utero exposure to gadolinium. When deciding which imaging modality to use, it’s important to weigh the risks of neuroimaging with risks of a new or worsening headache based on clinical signs and symptoms.

  1. What treatment options are available?

Although there are many treatment options for migraine, it’s important to note that some treatments can have adverse effects on babies — for example, third trimester use of ibuprofen can cause impaired renal function and premature closure of fetal blood vessels [6]. Reglan, also known as metoclopramide, is sometimes prescribed for migraine attacks, but its safety during pregnancy may depend on the individual’s health condition and the stage of the pregnancy. Lidocaine nasal spray is sometimes used in migraine during pregnancy due to its potential to provide local anesthesia and reduce pain [7]. In particular, it may be used to desensitize the nerves involved, and the nasal spray form allows for targeted delivery to the nasal passages, where it can act locally. While lidocaine nasal spray may be considered relatively safe in certain situations, its use during pregnancy should be evaluated on a case-by-case basis. Tylenol, or acetaminophen, is often considered a safer option for pain relief during pregnancy, including use in migraine [7]. However, this is at the discretion of the healthcare professional, and on a case-by-case basis. Nerve blocks have been noted to be safe due to minimal placental transfer, but the gold standard in safety are non-pharmaceutical approaches such as education, relaxation training, and biofeedback [7].

We hope this quick article can help you make a better informed decision on how to proceed if you have a headache during pregnancy. As always, stay well! – Dr. K

 

References:

  1. Maternal Changes During Pregnancy, Labor, and Birth | Anatomy and Physiology II. https://courses.lumenlearning.com/suny-ap2/chapter/maternal-changes-during-pregnancy-labor-and-birth/. Accessed 12 Dec 2023
  2. Boushra M, Rathbun KM (2023) Postpartum Headache. In: StatPearls. StatPearls Publishing, Treasure Island (FL)
  3. reVITALize: Obstetrics Data Definitions. https://www.acog.org/practice-management/health-it-and-clinical-informatics/revitalize-obstetrics-data-definitions. Accessed 12 Dec 2023
  4. Wabnitz A, Bushnell C (2015) Migraine, cardiovascular disease, and stroke during pregnancy: systematic review of the literature. Cephalalgia 35:132–139. https://doi.org/10.1177/0333102414554113
  5. Holle D, Obermann M (2013) The role of neuroimaging in the diagnosis of headache disorders. Ther Adv Neurol Disord 6:369–374. https://doi.org/10.1177/1756285613489765
  6. Ibuprofen Use During Pregnancy. In: Drugs.com. https://www.drugs.com/pregnancy/ibuprofen.html. Accessed 12 Dec 2023
  7. Treating Migraine During Pregnancy. In: American Headache Society. https://americanheadachesociety.org/news/treating-migraine-during-pregnancy/. Accessed 18 Jan 2024

 

Published On: January 18th, 2024