Migraine in pregnancy
Questionnaire/history:
Headache similar to previous ones?
Differences (particularly relating to aura)?
Past medical history?
Current medication?
Known drug allergies?
Examination:
Blood pressure?
Eye movements?
Visual field test?
Pupillary responses?
Fundoscopy?
Other neurological exam?
Investigations:
Urine dipstick?
Management:
Advised:
To keep well hydrated
To not skip meals
To reduce caffeine but to avoid abrupt withdrawal
Good sleep hygiene
Regular exercise
Acupuncture (some evidence)
Paracetamol
Ibuprofen (can be considered in 1st/2nd trimester)
To avoid opiates (as increase nausea and reduce gastric emptying)
Triptans (can be considered in refractory cases - reasonable safety evidence for sumatriptan; should be avoided in women with hypertension in pregnancy or those with pre-eclampsia)
Anti-emetic together with analgesia (even in absence of nausea/vomiting - can improve gastric motility/drug absorption):
- Cyclizine or prochlorperazine 1st line
- Ondansetron, domperidone metoclopramide may be considered 2nd line
(Notes: evidence of small increased risks of cleft palate with ondansetron MHRA 2020 (3 extra cases/10,000 births) if used in 1st trimester but data on cardiac defects is reassuring)
Prophylaxis:
Seek specialist guidance, if required:
Aspirin 75mg OD up to 36/40
B-blockers (eg propranolol 10-40mg TDS)
Amitriptyline 10-25mg nocte may be considered
(Note: Do not use valproate or topiramate (high teratogenicity risk), or ARBs (high risk in 2nd/3rd trimester)
Breastfeeding:
(Note: Relatively common for women to get migraine flares after delivery)
Paracetamol, NSAIDs, sumatriptan, propranolol and amitriptyline (low dose) are all thought to be safe with breastmilk concentrations not thought to be high enough to affect babies
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