See a virtual headache specialist in 1-2 days! Get HALF off your first month!

Migraine Book on Amazon

Migraine and Headaches During Pregnancy & Postpartum

Posted on May 19 2025, By: Cerebral Torque

← Back to Migraine Resource Hub
This content is sponsored by

Migraine and Headaches During Pregnancy & Postpartum

A comprehensive guide to diagnosis, management, and treatment options for expectant and new mothers
Updated May 2025
Quick Navigation - Pregnancy & Headaches Complete Guide
Understanding Headaches in Pregnancy When to Seek Medical Evaluation Types of Headaches During Pregnancy Diagnostic Evaluation Migraine Progression Throughout Pregnancy Treatment Approaches Neuromodulation Options Preventive Treatment Botox in Pregnancy Postpartum Headaches Treatment During Breastfeeding Refractory Migraine Management Imaging & Diagnostic Testing Migraine & Pregnancy Outcomes Cluster Headache Management Trimester-Specific Approaches

Understanding Headaches in Pregnancy

Headache is remarkably common among women in their childbearing years. Studies show that approximately 60% of women under 40 years of age report experiencing headaches within a given year. For pregnant women with a pre-existing headache condition, concerns about how pregnancy might affect their symptoms and how treatment might affect their baby are significant.

For women experiencing new-onset headaches during pregnancy or postpartum, diagnostic evaluation is essential as headaches may signal other pregnancy-related conditions that require prompt attention. The most concerning of these is preeclampsia, which must always be considered in any pregnant woman beyond 20 weeks of gestation who presents with headache.

When to Seek Immediate Medical Evaluation

Warning Signs Requiring Prompt Evaluation

  • Headache with altered mental status, seizures, vision changes, stiff neck, or neurological symptoms
  • Sudden onset of severe headache ("worst headache of my life")
  • New-onset migraine-type headache (especially after 20 weeks gestation)
  • Headache unrelieved by appropriate pain medication
  • Headache accompanied by high blood pressure (>140/90 mmHg)
  • Headache with fever or other signs of infection
  • Headache that wakes you from sleep
  • Change in the character of pre-existing headaches

Preeclampsia and Headache

Preeclampsia must be considered in every pregnant woman over 20 weeks of gestation with headache. Among pregnant women with no prior history of headache who develop a new or unusual headache, approximately one-third will have preeclampsia. This serious condition is characterized by high blood pressure (≥140/90 mmHg) and often accompanied by protein in the urine or other signs of organ dysfunction.

The headache associated with preeclampsia is typically:

  • Diffuse (holocephalic)
  • Constant and throbbing
  • Mild to severe in intensity
  • Often accompanied by blurred vision, photophobia, or confusion

These symptoms can sometimes be mistaken for migraine, though migraine pain is more frequently unilateral. If you experience these symptoms, especially if accompanied by high blood pressure, contact your healthcare provider immediately.

Types of Headaches During Pregnancy

Migraine
Often unilateral, throbbing pain with nausea, vomiting, and sensitivity to light/sound. 60-70% of women with pre-existing migraine improve during pregnancy (more details on this later).
Tension-Type Headache
Bilateral pressure or tightness, typically without nausea or sensitivity symptoms. Usually remains stable during pregnancy.
Cluster Headache
Severe, unilateral pain around the eye with autonomic symptoms like tearing and nasal congestion. Rare, but not typically affected by pregnancy.

Migraine During Pregnancy

Approximately 18% of women in the United States have migraine, with prevalence peaking during childbearing years. About 2% of women experience their first migraine during pregnancy, usually in the first trimester.

How Pregnancy Affects Migraine

  • 60-70% of women report improvement in migraine symptoms during pregnancy
  • 5% of women report worsening of migraine during pregnancy
  • 25-30% of women experience no change
  • Improvement is most likely in women with menstrual migraine and migraine without aura
  • Improvement is most common in women who experience relief in the first trimester

This pattern of improvement is likely due to the stable, elevated levels of estrogen during pregnancy. However, during the postpartum period, migraine often recurs as hormone levels rapidly fluctuate. Interestingly, breastfeeding appears to have a protective effect, with studies showing lower rates of migraine recurrence in breastfeeding mothers (43%) compared to non-breastfeeding mothers (100%).

Tension-Type Headache During Pregnancy

Unlike migraine, tension-type headaches typically do not change in frequency or severity during pregnancy, as they are not strongly influenced by hormonal fluctuations. Studies show that approximately 56-67% of women report no change in their tension headaches during pregnancy.

Cluster Headache During Pregnancy

Cluster headache is a less common, but extremely painful headache disorder characterized by severe unilateral pain with associated autonomic symptoms like tearing, nasal congestion, and facial sweating. Research suggests that pregnancy generally does not significantly affect the course of cluster headaches, though some women report remission during pregnancy.

Diagnostic Evaluation During Pregnancy

Evaluating headache during pregnancy requires a careful approach that balances thorough assessment with considerations for maternal and fetal safety.

Initial Evaluation

Most pregnant women with primary headache syndromes (tension-type headache, migraine, cluster headache, etc.) have been diagnosed before pregnancy. A patient with a prior history of headache may continue to experience headache during pregnancy without needing extensive diagnostic testing if:

  • Their characteristic symptoms have not changed
  • Preeclampsia has been excluded (in patients over 20 weeks gestation)
  • There are no "red flag" symptoms suggesting a serious underlying condition

"Red Flag" Symptoms Requiring Detailed Evaluation

  • Headache with altered mental status, seizures, or neurological signs/symptoms
  • Sudden onset of severe headache
  • New onset migraine type headache, especially after 20 weeks
  • Headache in an immunocompromised individual
  • Change in headache characteristics from usual headaches
  • Headache associated with fever, trauma, cough, exertion, or sexual activity
  • Headache that awakens the patient from sleep
  • Headache unrelieved by appropriate pain medication

Again, when a pregnant woman develops a new headache, particularly after 20 weeks gestation, preeclampsia must be considered!

Evaluating for Preeclampsia

Preeclampsia evaluation includes:

  • Blood pressure measurement (≥140/90 mmHg on two occasions at least 4 hours apart indicates hypertension)
  • Urine protein assessment (protein/creatinine ratio ≥0.3 or ≥0.3g in 24 hour collection)
  • Blood tests to assess for thrombocytopenia, liver function, and kidney function
  • Assessment for other severe features like right upper quadrant/epigastric pain or visual symptoms

Preeclampsia can typically be excluded in normotensive patients without proteinuria or other signs of organ dysfunction. However, in patients with mildly elevated blood pressure, watching for other features such as epigastric pain, visual symptoms, or laboratory abnormalities is important.

Differentiating Migraine from Preeclampsia Headache

Distinguishing between migraine and preeclampsia related headache can be challenging, especially since some symptoms overlap:

  • Migraine: Often unilateral, pulsating quality, history of similar headaches pre pregnancy, improves with appropriate migraine therapy, normal blood pressure and labs
  • Preeclampsia headache: Usually diffuse/holocephalic, constant/throbbing, associated with hypertension and/or proteinuria or other organ dysfunction, may be accompanied by visual changes or right upper quadrant/epigastric pain

When the distinction is unclear, it is safest to manage as potential preeclampsia until this diagnosis can be confidently excluded.

Approach to New Headache in Pregnancy

After excluding preeclampsia, approximately half of pregnant women with new onset headache have migraine and the other half have a variety of other causes. These patients should be evaluated with a detailed history and physical examination, including neurological assessment.

If the clinical picture suggests a serious underlying disorder, neuroimaging may be necessary. When possible, MRI without contrast is preferred during pregnancy due to absence of radiation exposure.

Progression of Migraine Throughout Pregnancy

The trajectory of migraine throughout pregnancy follows a distinct pattern for many women, though individual experiences can vary considerably. Understanding this typical pattern can help pregnant women anticipate changes and plan accordingly with their healthcare providers.

First Trimester

During the first trimester, many women actually experience temporary worsening of migraine before improvement begins:

  • The dramatic hormonal fluctuations, particularly rising estrogen and progesterone levels, can trigger more frequent or severe attacks initially
  • Morning sickness and its associated nausea can compound migraine symptoms
  • Sleep disturbances common in early pregnancy may trigger attacks
  • Stress related to the new pregnancy can be a migraine trigger
  • Women who discontinue preventive medications upon learning they are pregnant may experience rebound attacks
First Trimester Migraine Pattern

Many women report that weeks 8-12 are particularly challenging for migraine, with some experiencing their worst attacks during this period. By the end of the first trimester, approximately 30-40% of women begin to notice improvement, though this varies substantially between individuals.

For women with pure menstrual migraine (attacks occurring exclusively with menstruation), improvement often begins earlier as menstruation ceases.

Second Trimester

The second trimester typically brings significant relief for most migraine patients:

  • Hormonal levels stabilize, with estrogen remaining consistently elevated
  • Nausea and vomiting of pregnancy typically diminish
  • Sleep patterns may improve compared to first trimester
  • By mid-second trimester (around weeks 16-20), approximately 50-60% of women report substantial improvement
  • Some women experience complete remission of attacks during this period

Research indicates that women whose migraine did not improve by the second trimester are less likely to see improvement later in pregnancy. This pattern helps healthcare providers identify which pregnant women might need continued preventive strategies.

Third Trimester

For most women, the improvement in migraine continues or stabilizes during the third trimester:

  • By the third trimester, 60-70% of women report significant improvement or complete resolution
  • Stress, sleep disturbances, and physical discomfort associated with late pregnancy may trigger attacks in some women
  • Some women experience a slight increase in attacks in the final weeks before delivery
  • Women with migraine with aura tend to experience less improvement in the third trimester compared to those with migraine without aura

Tracking Migraine Changes During Pregnancy

Keeping a headache diary throughout pregnancy can be invaluable for several reasons:

  • Helps document patterns specific to your pregnancy
  • Allows for correlation with other pregnancy symptoms
  • Provides important information for healthcare providers
  • Facilitates distinguishing between typical migraine patterns and potential concerning headaches that require evaluation
  • Guides treatment decisions as pregnancy progresses

A simple paper diary or smartphone app can track frequency, duration, intensity, triggers, and response to treatments.

Labor, Delivery, and Immediate Postpartum

The labor and delivery period presents unique considerations for women with migraine:

  • Some women experience a migraine attack during or immediately after delivery
  • The dramatic drop in estrogen levels immediately postpartum is a common trigger
  • Sleep deprivation and stress associated with childbirth and newborn care can exacerbate symptoms
  • Women with a history of menstrual migraine are at particularly high risk for postpartum attacks

Later Postpartum Period

The postpartum period often sees a return of migraine patterns:

  • First postpartum week: approximately 34% of women with a history of migraine experience attacks
  • First postpartum month: approximately 55% experience the return of migraine
  • Breastfeeding appears protective: only 43% of breastfeeding women experience postpartum migraine versus 100% of non-breastfeeding women in some studies
  • The protective effect may be due to more stable estrogen levels in breastfeeding women
  • When weaning occurs, many women experience an increase in migraine frequency
The pattern of migraine improvement during pregnancy and recurrence postpartum closely follows estrogen levels, supporting the theory that estrogen withdrawal is a key trigger for many women with migraine. This understanding helps guide both prevention and treatment strategies throughout this reproductive transition.

Treatment Approaches During Pregnancy

The primary goal of headache treatment during pregnancy is maternal comfort. Treatment decisions are guided by balancing symptom relief with fetal safety considerations.

Patients should have realistic expectations regarding the limits of therapy, and clinicians should be willing to treat headache aggressively when the patient requests it after a discussion of the available information about potential fetal risks.

Acute Migraine Treatment During Pregnancy

Treatment Tier Medications Considerations
First-Line Acetaminophen, Acetaminophen and metoclopramide, Acetaminophen-codeine (limited use)

Acetaminophen (1000 mg) is considered the safest analgesic in pregnancy. Combination therapy may be more effective for moderate headaches. If acetaminophen-codeine is used, limit to no more than nine days per month to avoid medication overuse/adaptation headache and potential neonatal withdrawal.
Second-Line NSAIDs (naproxen, ibuprofen) Safest in second trimester before 20 weeks

Should be avoided after 30 weeks due to concerns about premature closure of the ductus arteriosus and other fetal effects. Short courses (<48 hours) between 20-30 weeks may be considered if benefits outweigh risks.
Third-Line Opioids Triptans

Opioids should be limited to the lowest effective dose for the shortest duration. Avoid chronic use due to risks of dependency, addiction, and medication overuse/adaptation headache.

Triptans, particularly sumatriptan, may be considered for moderate to severe migraine that doesn't respond to other treatments. Patient experience with sumatriptan has been generally reassuring, with no clear increased risk of birth defects or pregnancy loss in registry data.

Anti-nausea Medications

For nausea associated with migraine or from medication side effects:

  • H1 antagonists such as meclizine, diphenhydramine, or promethazine are preferred
  • Dopamine antagonists like metoclopramide, prochlorperazine, or chlorpromazine are effective but may cause acute dystonic reactions
  • Ondansetron may be used for severe nausea and vomiting

Medications to Avoid During Pregnancy

  • Ergotamine is absolutely contraindicated due to uterotonic effects and vasoconstriction
  • Isometheptene (not available in the US) combinations should be avoided due to potential effects on uterine blood flow

Non-Pharmacologic Approaches

Non-drug interventions are particularly important during pregnancy and may include:

  • Rest in a dark, quiet room
  • Cold or heat therapy
  • Massage
  • Regular meals and sleep schedules
  • Stress management techniques
  • Biofeedback and relaxation training
  • Cognitive behavioral therapy
  • Peripheral nerve blocks (for refractory headaches)
  • Neuromodulation:

Neuromodulation Options During Pregnancy

For pregnant women with frequent or debilitating headaches who wish to avoid medications, neuromodulation devices offer a promising non-pharmacological approach. These FDA-cleared devices are increasingly being considered as safer alternatives during pregnancy.

FDA-Cleared Neuromodulation Devices for Headache

  • Remote Electrical Neuromodulation (REN) - Wearable armband device that stimulates peripheral nerves
  • Non-invasive Vagus Nerve Stimulation (nVNS) - Handheld device applied to the neck
  • External Trigeminal Nerve Stimulation (eTNS) - Forehead electrode that stimulates supraorbital nerves
  • Single-pulse Transcranial Magnetic Stimulation (sTMS) - Portable device that delivers magnetic pulses to the occipital region
  • External Concurrent Occipital and Trigeminal Neurostimulation (eCOT-NS) - Headband that stimulates multiple nerve pathways

Safety Evidence During Pregnancy

While research specifically evaluating these devices in pregnant women is limited, preliminary data is encouraging:

Remote Electrical Neuromodulation
A retrospective survey of 140 pregnant women (59 using REN, 81 controls) found no statistical differences in gestational age, birth weight, preterm births, birth defects, or developmental milestones at three months.
Transcranial Magnetic Stimulation
Studies of repetitive TMS (rTMS) during pregnancy for depression treatment found no adverse effects on cognitive or motor development of children aged 18-62 months when compared to controls.
Vagus Nerve Stimulation
Animal studies suggest that vagus nerve stimulation does not impair pup viability or increase inflammatory markers. Limited human data on invasive VNS (44 pregnancies) suggests relative safety for mother and fetus.

Advantages of Neuromodulation During Pregnancy

  • Non-pharmacological approach avoids medication risks to the developing fetus
  • Can be used for both acute treatment and prevention strategies
  • Minimal side effects compared to many medications
  • Some devices (like REN, eTNS) have highest level of safety evidence during pregnancy
  • Can be used as either an alternative or adjunct to conventional treatments

When to Consider Neuromodulation

According to recent American Headache Society recommendations, neuromodulation devices may be particularly valuable for:

  • Women with contraindications to common headache medications
  • Those seeking to minimize medication exposure during pregnancy
  • Patients with inadequate response to first-line pregnancy-safe treatments
  • Women with frequent or debilitating headaches requiring preventive approaches
While at this time data is limited regarding the true safety of neuromodulation in pregnancy, studies conducted thus far on the available FDA-cleared devices do not appear to pose harm to the pregnant patient or developing fetus. More research is needed to further elucidate the safety and efficacy of neuromodulation when used during pregnancy.

Discuss with your healthcare provider if neuromodulation might be an appropriate option for managing your headaches during pregnancy, especially if you've had limited success with standard treatments or wish to minimize medication use.

Preventive Treatment During Pregnancy

For women with frequent or debilitating headaches during pregnancy, preventive therapy may be considered. The safest approach is to use the lowest effective dose of medications with established safety profiles.

First-Line Preventive Options:

  • Beta blockers such as propranolol and metoprolol are not teratogenic but may cause mild fetal growth restriction and transient neonatal effects with prolonged use
  • Calcium channel blockers like verapamil are commonly used in pregnancy for other indications without adverse effects
  • Cyproheptadine, an older antihistamine agent, appears to be safe during pregnancy

Second-Line Preventive Options:

  • Low-dose antidepressants such as venlafaxine (SNRI) or amitriptyline (TCA) may be considered, particularly for women with comorbid depression
  • Gabapentin should be avoided in the first trimester but may be an option later in pregnancy for refractory cases

Other Options:

  • Magnesium (400-800 mg daily)
  • Riboflavin (400 mg daily)
  • Peripheral nerve blocks with local anesthetic
  • Melatonin:

Emerging Evidence: Melatonin for Migraine Prevention

Melatonin (3-5 mg at bedtime) has shown promising results for migraine prevention in clinical trials. In one study comparing melatonin 3 mg to amitriptyline 25 mg and placebo:

  • Melatonin significantly reduced headache frequency compared to placebo
  • Melatonin's effect was comparable to amitriptyline
  • Melatonin had superior response rates and fewer side effects
  • Unlike amitriptyline (which caused weight gain), melatonin was associated with slight weight loss

While specific pregnancy safety data is limited, melatonin's favorable overall safety profile makes it an interesting option to discuss with your healthcare provider. Some studies even suggest a decrease risk of preeclampsia with melatonin use. 

OnabotulinumtoxinA (Botox) in Pregnancy

A 2025 study published in the journal Cephalalgia provides important data for pregnant women with chronic migraine who are considering OnabotulinumtoxinA (Botox) treatment. This prospective study from Hull, UK followed 126 women over 14 years (2010-2024) who became pregnant while receiving Botox treatment for chronic migraine.

100%
Migraine Remission
All women who continued Botox treatment during pregnancy maintained migraine remission, compared to only 31% of those who discontinued treatment.
77%
Continued Treatment
Over three-quarters of women chose to continue Botox treatment during pregnancy after receiving informed consent discussions.
2.4%
Miscarriage Rate
The overall miscarriage rate (2.4%) was not higher than general population rates, which range from 8% to 24%.

Key Findings on Botox During Pregnancy

This study provides valuable insights for women with chronic migraine who become pregnant while on OnabotulinumtoxinA treatment:

Study Highlights

  • High relapse risk when stopping treatment: 69% of women who discontinued Botox suffered a migraine relapse during pregnancy, typically 4-6 months after their last treatment.
  • Postpartum relapse common: Among women who stayed in remission during pregnancy after stopping Botox, 67% experienced a relapse within three months postpartum.
  • No adverse pregnancy outcomes: No fetal malformations were reported in any of the 126 pregnancies.
  • Women's preferences: Most women with previous children (83%) chose to continue treatment, while most first-time mothers (83%) chose to discontinue treatment.

The study authors note that despite the uncertain risks of OnabotulinumtoxinA in pregnancy, their real-world experience shows most women chose to continue treatment after informed discussion. This was largely due to previous treatment failures and fear of disabling migraine returning if treatment was stopped.

Official Guidance vs. Real-World Data

It's important to note that official guidance from regulatory agencies (UK MHRA and US FDA) still states that Botulinum Toxin is not recommended during pregnancy due to insufficient human data and some adverse outcomes in animal studies. However, this study adds to a growing body of evidence suggesting that OnabotulinumtoxinA treatment for chronic migraine may be effective in pregnancy without evident adverse pregnancy outcomes.

Always discuss with your healthcare provider to weigh the potential benefits against possible risks based on your individual situation.

Postpartum Headaches

The postpartum period presents unique challenges for headache management due to hormonal fluctuations, sleep disruption, stress, and other factors. Postpartum headaches may be primary (migraine, tension-type) or secondary to other conditions.

Common Causes of Postpartum Headache
  • Primary headaches (migraine, tension-type headache) - most common in women with prior history
  • Postdural puncture headache - following epidural or spinal anesthesia; characterized by positional pain that worsens when upright
  • Preeclampsia/eclampsia - can develop up to 6 weeks postpartum
  • Cerebral venous thrombosis - increased risk during puerperium
  • Other vascular disorders - RCVS, PRES, arterial dissection
  • Pituitary disorders - apoplexy, Sheehan syndrome

Evaluation of Postpartum Headache

The evaluation of postpartum headache follows similar principles as during pregnancy:

  • Exclude preeclampsia in patients with hypertension (can occur up to 6 weeks postpartum)
  • Consider postdural puncture headache in women who received neuraxial anesthesia
  • Evaluate for concerning features warranting neuroimaging (persistent severe headache, focal neurologic signs, fever, etc.)

Treatment During Breastfeeding

For breastfeeding mothers, medication selection should consider potential transfer into breast milk and effects on the infant. Many medications used for non-breastfeeding patients can be used safely, but some require caution:

Medications to Use with Caution or Avoid While Breastfeeding

  • Ergotamine - may cause vomiting, diarrhea, and unstable blood pressure in infants
  • Codeine and other opioids - may cause CNS depression in infants; genetic variations in metabolism can increase risk
  • Triptans - consider temporary interruption of breastfeeding (8-12 hours for sumatriptan, 24 hours for other triptans)
  • Combination products containing butalbital - not recommended

Most NSAIDs, acetaminophen, and many preventive medications are compatible with breastfeeding. For specific guidance, consult resources like LactMed or discuss with your healthcare provider.

Management of Refractory Migraine

For pregnant women with severe, refractory migraine attacks that do not respond to first-line treatments, additional options may be considered under close medical supervision.

First-Line Treatment for Refractory Attacks:

  • IV hydration with fluids to address dehydration
  • Antiemetics like prochlorperazine (10 mg)
  • IV opioids when necessary, with careful monitoring
  • Pretreatment with diphenhydramine (12.5 mg) to prevent akathisia from antiemetics

Second and Third-Line Options:

  • Magnesium sulfate (1-2g IV) - Though evidence for efficacy is mixed, it has a good safety profile in pregnancy
  • Glucocorticoids such as prednisone or methylprednisolone - Use should be limited to intractable cases; prednisone and methylprednisolone are preferred as they are metabolized by the placenta
  • Peripheral nerve blocks with local anesthetics - Case reports show effective relief for some pregnant patients with no adverse maternal or fetal effects

Benefits of Peripheral Nerve Blocks

Peripheral nerve blocks may be particularly valuable during pregnancy because they:

  • Avoid systemic medication exposure to the fetus
  • Can provide significant relief for refractory headaches
  • May break the cycle of a prolonged migraine attack
  • Can be performed in both outpatient and emergency settings
  • Most commonly target occipital, auriculotemporal, supraorbital, or supratrochlear nerves

In one study of pregnant women with headache and pain scores >3, occipital nerve block resulted in significant pain reduction for 58% of patients compared to only 32% with standard care.

Imaging and Diagnostic Testing During Pregnancy

If headaches warrant diagnostic imaging or other testing during pregnancy, several considerations come into play:

MRI
Preferred method for brain imaging during pregnancy. No ionizing radiation and no known adverse fetal effects. Avoid gadolinium contrast unless absolutely necessary.
CT Scan
Uses ionizing radiation, but fetal exposure from maternal head CT is minimal. Appropriate when MRI is unavailable or contraindicated and rapid diagnosis is necessary.
Lumbar Puncture
Not contraindicated during pregnancy. Should be performed after neuroimaging if increased intracranial pressure or infection is suspected.

The decision to use neuroimaging should balance the immediate need for diagnosis against potential risks. In non-acute settings, consultation with a neurologist and maternal-fetal medicine specialist can help determine if imaging can be deferred until after pregnancy.

Migraine and Pregnancy Outcomes

A comprehensive systematic review and meta-analysis published in May 2025 examined the association between migraine, its subtypes, and adverse pregnancy outcomes. This large-scale analysis included 19 studies encompassing over 1.4 million deliveries, providing important insights for pregnant women with migraine.

1.28×
Increased Risk of Preeclampsia
Women with migraine showed a 28% higher risk of developing preeclampsia compared to women without migraine.
1.30×
Increased Risk of Preterm Birth
Migraine was associated with a 30% increase in the risk of preterm birth.
1.07×
Small for Gestational Age
A small but statistically significant increased risk (7%) was found for babies being small for gestational age.

Migraine Subtypes and Pregnancy Risks

An important finding from this research is that both migraine subtypes appear to be associated with increased pregnancy risks:

Risks by Migraine Subtype

  • Migraine without aura (MO) was associated with a 62% increased risk of preeclampsia and a 28% increased risk of preterm birth
  • Migraine with aura (MA) showed an even higher association with preeclampsia (106% increased risk) and a 25% increased risk of preterm birth
  • The stronger association between migraine with aura and adverse outcomes may be related to its closer link to vascular and endothelial dysfunction

Biological Mechanisms

The research suggests several potential mechanisms that may explain the relationship between migraine and adverse pregnancy outcomes:

  • Both migraine and conditions like preeclampsia are associated with increased platelet activation
  • Migraine is linked to endothelial dysfunction, a key component in preeclampsia pathophysiology
  • Elevated levels of inflammation markers (like C-reactive protein) are found in both migraine and pregnancy complications
  • Reduced proangiogenic factors in individuals with migraine may contribute to vascular disorders during pregnancy

Clinical Implications

These findings suggest that women with migraine, especially those with aura, may benefit from:

  • Closer monitoring during pregnancy for signs of preeclampsia
  • Consideration of low-dose aspirin before 16 weeks gestation to potentially reduce preeclampsia risk (discuss with healthcare provider)
  • Increased awareness of preterm birth risk
  • Specialized headache management plans for pregnancy and postpartum periods
It's important to note that while these associations exist, most pregnant women with migraine will have normal pregnancies without complications. These findings help healthcare providers identify who might benefit from additional monitoring.

Special Management Approaches for Cluster Headache

Cluster headache, though less common than migraine or tension-type headache, presents particular challenges during pregnancy due to its severe and disabling nature. Treatments need to be both effective and safe for the developing fetus.

Acute Treatment Options:

First-Line Approaches

  • High-flow oxygen therapy (100% oxygen at 12-15 L/min) is the safest and often most effective acute treatment during pregnancy
  • Consider using a non-rebreather mask for optimal delivery
  • Continue for 15-20 minutes or until pain resolves
  • No known risks to the fetus

If oxygen therapy is insufficient, additional options may include:

  • Sumatriptan (subcutaneous or intranasal) - Registry data has been reassuring regarding safety
  • Topical lidocaine (4%) applied inside the nostril on the affected side - Extensive experience with local anesthetics in pregnancy suggests minimal systemic absorption

Medications to Avoid

  • Ergotamine is absolutely contraindicated during pregnancy due to vasoconstrictive and uterotonic effects

Preventive Treatment Options:

For cluster headache prevention during pregnancy, the following medications may be considered:

  • Verapamil - First-line preventive; relatively safe with good tolerability; typical dose 240-320 mg daily in divided doses
  • Prednisone or methylprednisolone - Short courses for breaking cycles; these are metabolized by the placenta to less active forms
  • After first trimester: Consider lithium or topiramate for refractory cases, but note first-trimester risks (Ebstein's anomaly with lithium; cleft lip/palate with topiramate)

For patients with cluster headache whose attacks occur primarily at night, melatonin (10 mg at bedtime) may be considered as a preventive option with a favorable safety profile.

Approach to Headache in Specific Trimesters

First Trimester Considerations

The first trimester is the critical period of organogenesis, making medication safety particularly important:

  • Emphasize non-pharmacological approaches whenever possible
  • Acetaminophen is the safest analgesic option
  • NSAIDs may be associated with a slight increase in miscarriage risk, but evidence is limited
  • Avoid teratogenic medications including valproate and topiramate
  • For women on preventive medications before pregnancy, individual risk-benefit assessment is needed

Second Trimester Considerations

With major organ formation complete, medication options expand slightly in the second trimester:

  • NSAIDs may be used for short courses (before 20 weeks of gestation)
  • Beta blockers like propranolol or metoprolol can be initiated if preventive therapy is needed
  • Triptans may be considered for severe migraines unresponsive to other treatments

Third Trimester Considerations

As delivery approaches, additional considerations come into play:

  • NSAIDs should be avoided after 30 weeks due to risks of premature ductal closure and other fetal effects
  • Monitor for preeclampsia vigilantly, particularly in women with a history of migraine with aura
  • Develop a delivery plan addressing pain management and headache treatment
  • Plan for postpartum headache management, particularly for women with a history of menstrual migraine

Creating a Delivery and Postpartum Plan

For women with significant headache disorders, creating a comprehensive plan with their healthcare team can be beneficial:

  • Discuss anesthesia options and risks/benefits (particularly regarding postdural puncture headache)
  • Plan for headache management during labor
  • Establish a strategy for postpartum headache management
  • Consider the impact of sleep disruption and develop strategies
  • If breastfeeding, review medication compatibility
  • Schedule follow-up with neurologist or headache specialist if needed

References

  1. Aegidius K, Zwart JA, et al. The effect of pregnancy and parity on headache prevalence: the Head-HUNT study. Headache. 2009; 49:851.
  2. MacGregor EA. Headache in pregnancy. Neurol Clin. 2012; 30:835.
  3. Sances G, Granella F, et al. Course of migraine during pregnancy and postpartum: a prospective study. Cephalalgia. 2003; 23:197.
  4. Headaches in Pregnancy and Postpartum: ACOG Clinical Practice Guideline No. 3. Obstet Gynecol. 2022; 139:944.
  5. Phillips K, Clerkin-Oliver C, et al. How migraine and its associated treatment impact on pregnancy outcomes: Umbrella review with updated systematic review and meta-analysis. Cephalalgia. 2024; 44:3331024241229410.
  6. Melhado EM, Maciel JA Jr, Guerreiro CA. Headache during gestation: evaluation of 1101 women. Can J Neurol Sci. 2007; 34:187.
  7. Bushman ET, Blanchard CT, Cozzi GD, et al. Occipital Nerve Block Compared With Acetaminophen and Caffeine for Headache Treatment in Pregnancy: A Randomized Controlled Trial. Obstet Gynecol. 2023; 142:1179.
  8. Wong HT, Khalil M, Ahmed F. OnabotulinumtoxinA for chronic migraine during pregnancy: a real world experience on 45 patients. J Headache Pain. 2020; 21:129.
  9. Marchenko A, Etwel F, Olutunfese O, et al. Pregnancy outcome following prenatal exposure to triptan medications: a meta-analysis. Headache. 2015; 55:490.
  10. Vgontzas A, Robbins MS. A Hospital Based Retrospective Study of Acute Postpartum Headache. Headache. 2018; 58:845.
  11. Smirnoff, L., Bravo, M. & Hyppolite, T. Neuromodulation for Headache Management in Pregnancy. Curr Pain Headache Rep 29, 14 (2025).
  12. Wong HT, Khan R, Buture A, Khalil M, Ahmed F. OnabotulinumtoxinA treatment for chronic migraine in pregnancy: An updated report of real-world headache and pregnancy outcomes over 14 years in Hull. Cephalalgia. 2025;45(5).
  13. Hansen AS, Christiansen CH, Rom AL, et al. Association between migraine, migraine subtype, and adverse pregnancy outcomes: A systematic review and meta-analysis. Acta Obstet Gynecol Scand. 2025; 104: 1026-1040.

This information is provided for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider for diagnosis and treatment of medical conditions.

MigraineScience Blog

Mon, Jun 16, 25

Migraine with Brainstem Aura

Comprehensive guide to Migraine with Brainstem Aura (MBA) - symptoms, diagnosis, treatment options, and latest research on whether it actually affects the brainstem. Patient-friendly explanations included.

Read More

Join Our Community