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A Lady with a Headache in the First Trimester 

A Lady with a Headache in the First Trimester
Chapter:
A Lady with a Headache in the First Trimester
Author(s):

M. Angela O’Neal

DOI:
10.1093/med/9780190609917.003.0013
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Subscriber: null; date: 26 September 2018

A 23-year-old woman who has migraine without aura is eight weeks pregnant. Her migraines had been well controlled with sumatriptan. She is now having her usual headaches with nausea and vomiting several times a week.

What do you do now?

Migraine

Natural History

Migraines occur three times more frequently in women due to hormonal influences. Menstrual exacerbation of headache is most commonly associated with migraine without aura. In pregnancy, due to changes in the level of estrogen, migraines are often more frequent in the first trimester. Particularly in women who have migraine without aura, 70–80% experience remission by the second trimester.1,2 Patients who have migraine with aura have a less predictable course during pregnancy, as these headaches are generally less hormonally triggered. Migraineurs have a higher risk of developing eclampsia.3

General Strategy

Given that migraine is both a benign disorder, and the natural history that the headaches will go into remission by the second trimester, prophylactic therapy is not generally utilized. In addition, use of prophylactic medications have a risk of teratogenicity and usually take at least four to six weeks to establish efficacy. Therefore, it is recommended to use medications at the time of the migraine attack only. Alternative therapies to minimize migraine triggers, such as stress management and acupuncture, are helpful alternatives to medication.

The pregnancy classification both for medications used for acute migraine and for migraine prevention are shown in Tables 13.1 and 13.2. In the patient who presents to the emergency room with migraine, one proposed strategy for treatment is suggested here. Intravenous (IV) fluids and IV magnesium are safe and effective treatments for migraine in pregnancy (Box 13.1). In refractory patients, the addition of steroids is reasonable. There is significant amount of data around the use of sumatriptan in pregnancy. No major congenital malformations have been identified in large retrospective trials. In the Norwegian registry, use of sumatriptan in the last trimester was associated with a small increase of bleeding during delivery related to uterine atony.4

Table 13.1 Abortive Therapies

Generic Name

Level of Risk in Pregnancy

Breastfeeding—Hale Lactation Rating

Acetaminophen

B

L1

NSAIDS:Ibuprofen Naproxen

B (D in 3rd trimester)

L1–L2

Metoclopramide

B

L2

Prochlorperazine

C

L3

Magnesium

A (D when used over 5–7 days)

L1

Triptans

C

L3

Dihydroergotamine

X

L4

Codeine

C (D at term)

L3

Butalbital

C

L3

Morphine

B (D at term)

L3

Prednisone

C (D in the 3rd trimester)

L3

Table 13.2 Preventative Medications

Drug Class

Generic Name

Level of Risk in Pregnancy

Hale Lactation Rating

Beta-blockers

Atenolol

D

L3

Metoprolol

C (D at term or prolonged use)

L3

Nadolol

C (D at term or prolonged use)

L4

Propranolol

C (D at term or prolonged use)

L2

Timolol

C (D at term or prolonged use)

L2

Migraine Management Postpartum

Postpartum, due to sleep deprivation, stress, as well as hormonal fluctuation, migraine frequency often increases. Unlike in pregnancy, there is little risk with use of nonsteroidal anti-inflammatory agents, and triptans are also safe. In addition, if needed, there are multiple safe choices for preventative therapy (Tables 13.1 and 13.2).5

Key Points to Remember

  1. 1. Migraines, especially migraine without aura, often go into remission in the second trimester.

  2. 2. Migraineurs have an increased risk of eclampsia.

  3. 3. Migraines during pregnancy are usually treated with abortive therapy only.

  4. 4. Alternative therapies such as biofeedback, stress management, and massage can be helpful adjunctive treatments for certain patients.

References

1.Sances G, Granella F, Nappi Re, et al. Course of migraine during pregnancy and postpartum: a prospective study. Cephalalgia. 2003;23:197–205.Find this resource:

2.MacGregor EA. Headache in pregnancy. Continuum Neurol. 2014;1(2):128–147.Find this resource:

    3.Marcoux S, Bérubé S, Brisson J, et al. History of Migraine and Risk of Pregnancy-Induced Hypertension. Epidemiology 1992;3:53-56.Find this resource:

    4.Nezalova-Henriksen K, Spigset O, Nordeng H. Triptan exposure during pregnancy and the risk of major congenital malformations and adverse pregnancy outcomes: results from the Norwegian Mother and Child Cohort Study. Headache. 2010;50(4):563–575.Find this resource:

    5.Klein AM, Loder E. Postpartum headache. In J Obstet Anesth. 2010;19:422–430.Find this resource: