Pregnancy and breastfeeding
Key issues for women who have migraine and become pregnant
Migraine in pregnancy
Hormonal change in women is a common trigger for those prone to migraine. This is often shown in pregnancy when the sex hormone levels show profound changes which has an effect on whether your migraine get better or worse. Oestrogen sometimes reaches one hundred times the normal level, whilst progesterone levels decrease, rising again towards the end of the pregnancy. However, the fluctuation of levels is not as pronounced as during the non-pregnant state, which may be why migraine often improves during pregnancy. This improvement may also be due to the increased levels of natural pain-killing hormones (endorphins). These are several times higher during pregnancy, and though the relief from migraines they provide might last the whole pregnancy, the levels settle back down after delivery, normally allowing migraine attacks to recur.
However, it is not always the case that your migraine will improve, especially in the early weeks of pregnancy. For some women, migraine can go on unchanged, or more rarely even get worse. During breastfeeding, stable oestrogen levels may be protective against having headache again after pregnancy.
Planning a pregnancy
If you are taking regular medication for your migraine and are planning a pregnancy, you should see your doctor for advice on the management of your migraine before and during pregnancy, after the birth and while you breast feed.
Migraine without aura in pregnancy
Studies show that migraine without aura improves after the first three months of pregnancy for about 60-70% of women. This is the case especially if your migraine has been linked to your menstrual cycle.
Migraine with aura in pregnancy
If you experience migraine with aura you are more likely to continue to have attacks during your pregnancy. Also if you experience migraine for the first time while you are pregnant it is likely to be with aura.
If you do think you are experiencing migraine for the first time whilst you are pregnant it is important to visit your GP so the causes for your head pain can be found and treated if necessary. Pre-eclampsia and other more serious causes of headache can have symptoms similar to migraine.
Conventional medication and pregnancy
If you are taking any prophylactic (preventive) treatments you should discuss stopping these or switching to a safer alternative with your doctor. It is advisable to take as few drugs as possible in the lowest effective dose and ideally all drug treatments should usually be avoided whilst you are pregnant.
Most of the evidence for the safety of drugs in pregnancy is circumstantial as drugs cannot usually be tested on pregnant or breast feeding women for ethical reasons. This means the advice regarding drug treatments for migraine in pregnancy will usually err on the side of caution.
During pregnancy and breastfeeding the preferred treatment strategy should always be a non-pharmacological one. Nevertheless, poorly controlled headache can lead to stress, sleep deprivation, depression and poor nutritional intake which in turn can have negative consequences for mother and baby. Therefore, if non-drug options become inadequate, a considered choice should be made concerning the use of medication, taking into account all the benefits and possible risks, in consultation with your doctor. A general rule should be to aim for the lowest effective dose and the shortest duration of treatment.
For treating a migraine attack as it begins, paracetamol is the drug considered safe during pregnancy and breast feeding. This should be taken in soluble form at the earliest signs of an attack, preferably together with something to eat. Aspirin has been used by many pregnant women in the first and second terms of pregnancy. Aspirin should be avoided nearer to the expected time of the birth as it can increase bleeding. Ibruprofen should not be taken in doses over 600mg per day.
Considerable data is available on the use of sumatriptan in pregnancy. A few large pregnancy registries covering more than 3,000 pregnancies, have analysed the use of other triptans, in particular rizatriptan, zolmitriptan and eletriptan and found no major congenital defects. The risk of major malformations has been reported as similar to the risk in the general population.
If you need anti-sickness drugs for your migraine, the following have been widely used in pregnancy without evidence of harm: buclizine, chlorpromazine and prochlorperazine. Domperidone and metoclopramide are safe in pregnancy, but they are probably best avoided in the first three months. Again, you will need advice from your doctor on what is best for you.
If none of these approaches work, it would be worth speaking to your doctor about a greater occipital nerve injection, which is a small injection of a local anaesthetic and steroid which is injected into the back of the skull, underneath the skin into the muscle around a large nerve which is involved in headache disorders. This is a quick procedure which can provide short to medium term relief, and can be organised through a headache neurologist. It is safe in pregnancy.
For preventive treatment, the lowest effective dose of propranolol is considered to present the lowest risk in pregnancy and breast feeding. Prolonged use may have adverse effects on the baby. Amitryptiline is a safe alternative, and there are no reports of adverse outcomes using pizotifen in pregnancy and breast feeding. Increasingly transcranial magnetic stimulation using the SpringTMS device is being used for migraine treatment and prevention, and has been deemed safe during pregnancy and breastfeeding by the European and American bodies.
The first three months of pregnancy
During the first three months the symptoms of pregnancy can make your migraine worse. Morning sickness can mean that you feel like eating and drinking less which can cause low blood sugar and dehydration. If you are not careful this can make your migraines worse. You should try to eat small frequent meals and drink frequent small amounts of water to prevent this. You will also be helping reduce any pregnancy sickness.
After the birth
For some women migraine returns with the return of their periods (see our menstruation information). Some mothers find they have a bad attack within a couple of days of giving birth. This may be due to the sudden drop in oestrogen levels after the birth. Exhaustion, dehydration, erratic sleep and low blood sugar after giving birth may all play a part.
Migraine and your baby
There is no evidence that migraine (with or without aura) has an effect on the outcome of the pregnancy. Migraine in a mother does not harm or endanger her baby.
If you breast feed your baby it is still best to avoid medication as far as possible because the baby will be taking whatever you take through the milk. The same drugs used in pregnancy can be taken whilst breastfeeding with the exception of aspirin. The aspirin which enters the breast milk could impair blood clotting in susceptible babies and so is best avoided.
If you need to take aspirin or other non recommended medication, such as the anti sickness drug metoclopramide, whilst you are breastfeeding it is best to not to breastfeed for 24 hours after the last dose. Ideally, keep some expressed milk in the freezer for such occasions; otherwise you will need to give formula milk. Although you may feel too unwell to do so, it is best to express milk at the usual feeding times but this will need to be thrown away. This can help ease discomfort as the breasts become engorged with milk and will help to prevent milk production diminishing.
Sumatriptan use in breastfeeding is considered safe as minimal amounts of the drug are available in the breastmilk. Less evidence has been collected on the other triptans and as such breastmilk may be best discarded if breastfeeding 24 h after use of these triptans as extra safety precaution.
Complementary and alternative medicine
Many women prefer to take complementary and alternative medicines such as homoeopathic and herbal remedies rather than traditional medicines whilst they are pregnant, considering them to be milder. It is important to remember some complementary treatments can have an unwanted effect on your pregnancy just as conventional medicines can. For instance, some women find aromatherapy massage very helpful, and may be unaware that some essential oils (rosemary for example) need to be avoided. Reflexology treatment is not always advisable during pregnancy, and all complementary medicines should be taken under supervision of a qualified practitioner. Feverfew should not be used during pregnancy.
Non-drug treatments certainly can be helpful, and massage, acupuncture, relaxation and biofeedback have been found to be useful by some. Some women also find applications of heat or cold to the head can be useful.
The best advice is to take as few drugs as is practically and realistically possible for you, and at the lowest effective dose. The use of any drugs or herbal remedy to treat your migraines during pregnancy and whilst breast feeding is a balance of risk and benefits. Always remember that if you are getting more than 2 or 3 headaches a week you should discuss this with your doctor rather than take over the counter painkiller as it is possible to develop a condition known as ‘medication overuse headache’. Any medication you do take should be recorded in your pregnancy notes.
As far as you can: rest and that way avoid becoming over-tired. Not everyone is able to stop and go to bed, but planning ahead, setting a regular routine and delegating work or household tasks whenever possible can often help.
- The Breastfeeding Network www.breastfeedingnetwork.org.uk