How to safely keep migraines at bay during pregnancy

Pregnancy should be a joyous time and not riddled with worries around being able to manage migraines.

Migraines are a highly prevalent disease that affects more women than men, peaking during childbearing years. While some women experience an improvement during pregnancy, others notice no change in their migraines and some experience worsening symptoms.

The first trimester tends to be the most problematic for migraines, but studies show a 50% improvement by week 12 and an 80% improvement by the second trimester due to increasing levels of estrogen. Those with migraine aura are less likely to improve while those with menstrual-related migraines may see a benefit.

An American Registry for Migraine Research study found nearly 20% of female participants who were patients at headache clinics avoided pregnancy due to migraines. They expressed concern that migraines would be more severe during pregnancy, migraine disability would make pregnancy more difficult or migraine medications may impact the developing fetus.

Women should not have to decide whether to have children due to migraines. Instead, health care providers should give patients successful tools and options to support them along their pregnancy journey. Migraine attacks that are left untreated or are unsuccessfully treated may become more frequent, more severe and longer lasting. Migraine attacks associated with vomiting can lead to dehydration and electrolyte imbalances, affecting not only the mother but also putting stress on the fetus.

There are options available to manage migraines during pregnancy. Non-pharmacologic options are often the first line of defense.

For example, it’s important to follow basic headache hygiene using the mnemonic “SEEDS”:

• Sleep. Prioritize sleep hygiene and treat sleep disorders.
• Eat. Avoid skipping meals and consider an elimination diet to identify migraine-triggering foods.
• Exercise. Physical activity can decrease migraine frequency due to the release of natural hormones.
• Diary. Keep track of your migraines to help your doctor provide a diagnosis and treatment.
• Stress. Reduce your stress by seeking help from a mental health expert and/or practicing mindfulness.

Additionally, biofeedback, yoga, physical therapy, dry needling and acupuncture are all alternative treatments with proven outcomes.

There is some evidence that nutraceuticals, such as magnesium, B2 and CoQ10, can help prevent migraines, but not all vitamins are considered safe in pregnancy. For mild to moderate attacks, you can try over-the-counter medications such as acetaminophen.

If ineffective, anti-emetics, such as metoclopramide, combined with diphenhydramine can be prescribed. Triptans, medications that treat migraines, are typically used as second line treatment if needed. To prevent migraines, some oral prescriptions can be effective, such as propranolol and even Botox injections. However, have a conversation with your health care provider before trying any new medications or vitamins.

Many headache specialists find neuromodulation to be a safe, effective alternative or adjunct to migraine treatment during pregnancy. These non-invasive devices modulate pain signals externally by acting directly on the nervous system. In my practice, I commonly use external trigeminal nerve stimulation (eTNS) and remote electronic neuromodulation (REN). While we do not have direct data during pregnancy, many headache specialists are comfortable prescribing them.

Overall, it’s important to have your migraines during pregnancy evaluated since they are a risk factor for many types of secondary headaches, such as central venous thrombosis, pregnancy-associated stroke and preeclampsia.

Dr. Ashley Holdridge is a neurologist at Aurora Health Care.

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