Migraine Management During Pregnancy, Breastfeeding, and Pregnancy Planning
Posted on December 17 2025,
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Migraine Management During Pregnancy, Breastfeeding, and Pregnancy Planning
Comprehensive guidance for safe and effective care
Introduction: Unique Challenges in Migraine Management
Migraine is a common neurological disorder that predominantly affects women during their reproductive years, presenting unique challenges in the context of pregnancy, breastfeeding, and pregnancy planning. Managing migraine during these periods requires careful consideration of both maternal well-being and fetal or infant safety.
8%
Pregnant Women
Experience worsening migraine symptoms or develop new-onset migraine during pregnancy
60-70%
Improvement Rate
Women experience migraine improvement during second and third trimesters due to hormone stabilization
Early Postpartum
Symptom Return
Migraine symptoms frequently recur in the early postpartum period due to rapid estrogen drop
Why This Matters
While many women experience migraine improvement during pregnancy, those who continue to have attacks need safe and effective management options. Additionally, the association between migraine and pregnancy-related complications necessitates careful monitoring throughout gestation.
Migraine and Pregnancy-Related Complications
Women with migraine face an increased risk of pregnancy-related adverse events. Understanding these risks is an important part of pregnancy counseling and monitoring.
Increased Risk Factors in Women with Migraine
Preeclampsia: Women with migraine have a 2.05-increased risk of preeclampsia compared with those without migraine. The risk is pronounced in women with migraine with aura.
Preterm Birth: The risk of preterm birth is increased by 26% in women with migraine.
Stroke Risk: Although absolute risks are low (0.1-0.3%), women with migraine have an 8.46-increased risk of ischemic and hemorrhagic stroke during pregnancy and the puerperium. This association is strongest for migraine with aura.
Miscarriage: Some studies have suggested a possible association between triptan use and miscarriage risk, but the evidence remains inconclusive and further research is needed.
Pathophysiological Mechanisms
Several mechanisms may link migraine and pregnancy complications:
- Endothelial Activation: Mediated by hypercoagulable and proinflammatory states
- Hypercoagulable States: Associated with migraine and potentially worsening pregnancy outcomes
- Cortical Spreading Depression: Underlying migraine aura may cause episodes of cerebral hypoperfusion, particularly during pregnancy when rising estrogen levels increase the risk
Clinical Implication
Careful monitoring of pregnant women with migraine is essential, especially those with the aura subtype. However, specific primary prevention with antithrombotic agents cannot be recommended as there is no evidence of potential benefits. Assessment should include awareness of both vascular and non-vascular adverse events, such as postpartum depression.
Non-Pharmacological Approaches: First-Line Options
Whenever possible, non-pharmacological approaches should be prioritized for both acute symptom relief and preventive therapy during pregnancy, given their safety profile and minimal risk to mother and fetus.
Treatment Principle
Despite their benefits, non-pharmacological strategies alone may not provide sufficient pain relief during pregnancy. Migraine is a serious neurological disease, and its attacks can be profoundly disabling. Women with persistent or severe migraine should not be left untreated and require appropriate management, ideally under the care of a physician with expertise in migraine.
Lifestyle Modifications and Education
Education alone, including awareness of triggers, is beneficial for migraine management. Lifestyle recommendations include:
- Stress Management: Personalized interventions to reduce stress
- Healthy Diet and Hydration: Regular meals and adequate fluid intake
- Limited Caffeine Intake: Up to 200 mg daily or 3 mg/kg body weight is considered safe during pregnancy
- Sleep Hygiene: Regular sleep schedule and management of insomnia
- Physical Exercise: Generally recommended during pregnancy for overall health benefits, though direct evidence for migraine relief during pregnancy is limited
Complementary and Integrative Therapies
| Therapy | Evidence Level | Considerations |
|---|---|---|
| Relaxation Therapy | Low-quality evidence for reducing migraine attack frequency | Widely accessible, safe during pregnancy, may be combined with other interventions |
| Cognitive Behavioral Therapy | Low-quality evidence for migraine reduction | Can be effective when combined with other approaches, addresses psychological aspects of pain |
| Mindfulness-Based Interventions | Low-quality evidence | Increases self-efficacy, alters pain perception, widely accessible via apps |
| Acceptance and Commitment Therapy | Shown to reduce migraine disability | Integrates cognitive behavioral therapy and mindfulness concepts |
| Yoga | Low-quality evidence for reducing migraine frequency and intensity | Also increases odds of normal vaginal birth and improves maternal anxiety, depression, and stress |
| Acupuncture | Safe and effective for migraine prevention in general population | Likely safe in pregnancy, very low-quality evidence suggests it may improve migraine frequency and severity |
Important Note on Evidence
None of these integrative treatments has been specifically tested in pregnant women with clinical trials, resulting in insufficient direct evidence. However, given the scarcity of alternative treatment options and the safety of these interventions, their use in pregnant women appears justified.
Non-Invasive Neuromodulation
Detailed article on neuromodulation
Non-invasive neuromodulation uses external devices to stimulate specific regions of the central or peripheral nervous system. These devices offer a non-pharmacological alternative, minimizing potential risks to both mother and fetus.
Available Neuromodulation Devices
Single-Pulse Transcranial Magnetic Stimulation (TMS): Creates a magnetic field that induces an electrical current to the cerebral cortex, changing neuronal firing patterns. Effective for both acute and preventive treatment.
Vagus Nerve Stimulation (VNS): Applies electrical current to the vagus nerve, which can modulate trigeminal activation. A large trial showed effectiveness for acute migraine treatment.
External Trigeminal Nerve Stimulation (eTNS): Delivers electrical stimulation to the supraorbital nerve. Clinical trials showed superiority over sham stimulation for both acute and preventive treatment.
Remote Electrical Neuromodulation (REN): Activates endogenous descending analgesic mechanisms through sub-pain-threshold stimulation delivered over the arm. Effective for both acute and preventive migraine treatment.
50
Subjects in Safety Studies
Clinical studies reported use of TMS during pregnancy with no adverse outcomes
140
Women in REN Study
Retrospective study showed no differences in safety outcomes between REN-exposed and non-exposed pregnant women
When available, non-invasive neuromodulation devices offer an option for managing migraine in pregnant women, particularly TMS and REN, which can be used for both acute treatment and prevention. However, their use is often limited by availability, cost, and coverage.
Pharmacological Treatment During Pregnancy
The use of drugs during pregnancy poses potential risks to the fetus by crossing the placenta or impairing the course of pregnancy. The impact is largely determined by the stage of fetal development, placental permeability, maternal health, drug potency, and dosage.
Critical Developmental Windows
- Pre-implantation Stage (within 20 days of fertilization): "All-or-nothing" effect - either embryo death or no effect, with teratogenesis being unlikely
- Organogenesis (20-56 days after fertilization): Most vulnerable period for teratogenic effects, leading to structural abnormalities or spontaneous abortion
- Second and Third Trimesters: Teratogenesis less likely, but drug exposure can impact growth and functional development of fetal organs
Acute Treatment Options
| Medication | Safety Profile | Recommendations |
|---|---|---|
| Acetaminophen (Paracetamol) | No increased risk for adverse maternal or fetal outcomes at normal doses (<4000 mg daily). Some evidence suggests potential adverse effects on fetal neurodevelopment | First-choice medication due to favorable safety profile. Can be used across all pregnancy |
| NSAIDs (Ibuprofen, Naproxen) | Use during first trimester associated with miscarriage and congenital malformations. After 24 weeks: fetal renal insufficiency. After 35 weeks: premature closure of ductus arteriosus | Can be used during second trimester ONLY. Ibuprofen preferred due to shorter half-life |
| Triptans (Sumatriptan) | Animal studies showed developmental toxicity. Human data do not suggest increased risk of birth defects. Potential risk for miscarriage as a class | Sumatriptan has most safety data. Can be considered as third-line treatment after acetaminophen and NSAIDs (during second trimester) |
| Metoclopramide | Animal and human observational studies suggest no association with congenital defects. Check neonates for extrapyramidal signs | May be considered for nausea and vomiting |
| Ondansetron | Limited human studies have not shown increased risk of congenital defects | Can be used for nausea if needed |
| Ergot Derivatives | Teratogenic | Should NOT be used |
Preventive Treatment Options
| Medication | Safety Profile | Recommendations |
|---|---|---|
| Beta Blockers (Propranolol, Metoprolol) | Can lead to decreased placental perfusion, fetal/neonatal bradycardia and hypoglycemia. Not associated with congenital defects | Safe during pregnancy. Best oral option. Discontinue at end of third trimester to avoid fetal/neonatal bradycardia and hypoglycemia |
| Amitriptyline | Teratogenicity of tricyclic antidepressants has no clear proof. Potential for harm to fetus or neonate exists | Can be used during pregnancy only after careful evaluation of risk/benefit ratio. Safest option after beta blockers |
| Topiramate | Associated with neurodevelopmental issues, neural tube defects, and cleft palate | Should be AVOIDED. Teratogenic |
| Valproate | Can cause fetal malformations, cognitive deficits, and autism | Must be AVOIDED. Teratogenic |
| ACE Inhibitors & ARBs (Lisinopril, Candesartan) | Risk of miscarriages, renal and pulmonary malformation, oligohydramnios. Particularly harmful during second and third trimester | Should be AVOIDED |
Important Safety Reminder
Undertreatment of migraine not only results in persistent pain and reduced quality of life, but also increases maternal psychological distress, which has been associated with adverse neurodevelopmental outcomes in offspring. Given limited safety data for several treatments, shared decision-making between patients and healthcare providers is essential.
Newer Migraine-Specific Treatments
Calcitonin Gene-Related Peptide (CGRP) Pathway Inhibitors
CGRP is the main therapeutic target for recently marketed migraine-specific treatments, including monoclonal antibodies (CGRP-mAbs) for prevention and gepants for acute attacks or prevention. While these treatments showed excellent efficacy and safety in the general migraine population, their use during pregnancy requires special consideration.
CGRP's Role in Pregnancy
In humans, CGRP plays a critical role in:
- Vascular regulation
- Placental development
- Decidualization
- Maintaining low vascular resistance in fetoplacental circulation
CGRP levels naturally rise during pregnancy, peaking in gestation and decreasing postpartum. Reduced CGRP activity is linked to hypertensive disorders of pregnancy like pre-eclampsia.
Animal and Preclinical Evidence
Rat Studies: CGRP receptor blockade increased uterine contractility. Near-term infusion of CGRP receptor antagonist reduced offspring weight and increased mortality.
Monkey Studies: Preclinical studies using erenumab in cynomolgus monkeys did not demonstrate adverse effects on pregnancy, fetal development, or postnatal growth at clinical doses. However, placental transfer was observed, with measurable serum levels in infants up to three months postpartum.
Human Evidence on CGRP Pathway Inhibitors
Current human evidence on potential risks remains limited, originating from case reports and pharmacovigilance studies based on spontaneous safety reports.
| Study Type | Findings | Limitations |
|---|---|---|
| Case Reports | Women exposed to CGRP-mAbs during pregnancy have not shown significant adverse events directly attributable to the drugs | Very small numbers, anecdotal |
| 2024 Pharmacovigilance Study (VigiBase) | 467 safety reports on CGRP-mAbs or gepants86% during pregnancy). No disproportionate reporting of pregnancy-related or fetal/neonatal outcomes compared with triptans | Reporting bias, lack of precise exposure timelines, challenges distinguishing treatment-related events from unrelated ones |
| Ongoing Registries | Pregnancy registries for ubrogepant, rimegepant, and atogepant will provide valuable data | Data not yet available |
Clinical Recommendations
CGRP-mAbs and gepants should best be avoided during pregnancy due to insufficient safety data. Additionally, potential effects such as changes in maternal blood pressure and potential risk of maternal adverse outcomes should be carefully considered given the critical role of CGRP in regulating uteroplacental blood flow.
If exposure occurs: Cases of unintended exposure should be reported in pregnancy registries to improve understanding of safety profiles.
OnabotulinumtoxinA
OnabotulinumtoxinA (BTX-A) is a neurotoxin approved for chronic migraine treatment. It is administered intramuscularly at predefined sites in the head and neck, with highly localized action that minimizes systemic exposure.
126
Women in Prospective Study
Updated study confirmed safety of BTX-A during pregnancy
397
Pregnancies Analyzed
29-year retrospective analysis showed fetal defect prevalence comparable to non-treated women
Clinical Recommendation
BTX-A may be considered in pregnant women with chronic migraine and significant disease burden if other options failed. The decision should involve thorough discussion with the patient, carefully weighing potential risks and benefits. Informed consent is essential to ensure shared decision-making.
Peripheral Nerve Blocks
Peripheral nerve blocks target nerves like the greater occipital nerve using local anesthetics (lidocaine, bupivacaine) and sometimes corticosteroids. Given uncertainty surrounding benefits of adding steroids and concerns regarding systemic absorption, the use of anesthetics alone is preferable during pregnancy.
Clinical Evidence
Retrospective Study (27 blocks in 13 pregnant women): Blocking nerves with 1-2% lidocaine or 0.5% bupivacaine effectively reduced pain intensity. Adverse pregnancy outcomes included two preterm deliveries and one spontaneous abortion at 17 weeks.
Case Report: Successful treatment of refractory migraine at 36 weeks gestation using sphenopalatine ganglion block with 4% lidocaine.
Although evidence remains limited, peripheral nerve blocks may be a safe and effective option for managing migraine in pregnant women. Among local anesthetics, lidocaine is safer than other drugs of the class due to its more limited effects on the fetus.
Nutraceuticals
Nutraceuticals are derived from food or plants and include vitamins, minerals, and supplements. While evidence is limited, they may be considered given restricted alternative treatment options during pregnancy.
| Nutraceutical | Evidence | Safety in Pregnancy |
|---|---|---|
| Magnesium | Well-studied for migraine prevention, effective and safe | Can safely be used in low doses (365 mg daily or less) throughout pregnancy. Also adjunctive treatment for preeclampsia. Risk of neonatal hypotonia with high doses |
| Riboflavin | Limited data available | Only one observational study suggested safety during pregnancy |
| Coenzyme-Q10 | Limited data available | Safety data not available |
| Melatonin | Good safety and efficacy data for migraine prevention | Safety relies on limited and heterogeneous observational data |
| Ginger | Probably effective as acute treatment, not preventive | Randomized trial showed similar efficacy to sumatriptan with better safety |
| Feverfew & Butterbur | Controversial data for migraine prevention | UNSAFE in pregnancy |
Migraine Management During Breastfeeding
Medication selection during breastfeeding should focus on minimizing infant exposure while ensuring effective migraine control for the mother. While most medications have lower concentrations in breast milk than in maternal plasma, even minimal exposure may pose risks, particularly for preterm or medically fragile infants.
Treatment Principles
Adjusting the timing of drug administration, such as taking medication immediately after breastfeeding, can help minimize infant exposure. Shared decision-making and thorough counseling are crucial when pharmacological treatment is necessary.
Acute Treatment Options During Breastfeeding
| Medication | Evidence | Recommendations |
|---|---|---|
| Acetaminophen (Paracetamol) | Small amount passes into breast milk | Can be used; first option |
| Ibuprofen | Short half-life, appears in breast milk at very low levels, safe for infants | Can be used |
| Other NSAIDs (Diclofenac, Naproxen) | Limited information indicates low levels in breast milk. Naproxen has longer half-life | Can be used if necessary. NSAIDs with shorter half-life preferred. Advisable to withhold breastfeeding for 8-12 hours |
| Triptans | Evidence insufficient. Sumatriptan best studied with low oral bioavailability and milk concentration. Eletriptan has very low concentration in breast milk | Sumatriptan and eletriptan can be used. Advisable to withhold breastfeeding for 8-12 hours. Triptans with high bioavailability should be avoided |
| Metoclopramide | No association with negative effects in breastfed infants. One case report of extrapyramidal syndrome in 21-week-old boy 48 hours after maternal exposure | Use with caution; risk-benefit ratio should be weighed. Can cause depression; avoid in postpartum women with history of major depression |
| Gepants | Lack of evidence. Drug level in breast milk supposed to be low | Alternate drug may be preferred until more data available, especially while nursing newborn or preterm infant. Advisable to withhold breastfeeding for 8-12 hours |
Preventive Treatment Options During Breastfeeding
| Medication | Evidence | Recommendations |
|---|---|---|
| Beta Blockers (Propranolol, Metoprolol) | Pass into breast milk at very low levels, especially metoprolol. Reversible bradycardia and hypoglycemia reported in one prospective survey | Can be considered with monitoring of side effects |
| Amitriptyline | Passes in low levels. Generally safe, not associated with adverse effects on infant growth and development. May be sedative for infant | Can be considered with monitoring of side effects |
| Candesartan | Very low levels in breast milk | Can be considered with monitoring of side effects |
| Lisinopril | Not enough evidence available. Low levels in breast milk | Can be considered with monitoring of side effects |
| Topiramate | Sedation and diarrhea reported. No long-term adverse effects on growth and development | Use with caution. Monitor for diarrhea, drowsiness, and developmental milestones |
| Valproate | Low levels in breast milk. No definite adverse reactions reported. Infants at risk for hepatotoxicity, thrombocytopenia, baldness | Use with caution. Monitor for jaundice, signs of liver damage, and bleeding |
| OnabotulinumtoxinA | Low levels in breast milk. No risk for infant botulism reported. No data for doses used in migraine prevention | Can be used |
| CGRP-mAbs | No data available. Levels in breast milk probably low due to high molecular weight. Even if present, unlikely to be absorbed by infants | Alternate drugs may be preferred until more data available |
| Peripheral Nerve Blocks (Lidocaine) | Data available on lidocaine. No adverse effects reported on infants | Lidocaine can be used |
When Breastfeeding Discontinuation May Be Necessary
In cases where migraine is severe and requires a medication that is contraindicated during breastfeeding, discontinuation of breastfeeding should be considered to prioritize maternal health while ensuring infant safety. Effective migraine management not only benefits the mother, but also enhances her ability to care for her child.
Migraine Management in Women of Childbearing Age and During Pregnancy Planning
Migraine predominantly affects women of childbearing age, requiring careful consideration of both unplanned and planned pregnancies when managing treatment. When prescribing migraine treatments, it is crucial to consider the potential for pregnancy, especially when using medications known to be harmful during gestation or those with insufficient safety data.
Key Principles for Women of Childbearing Age
Contraception Recommendation: Contraception should be recommended when prescribing certain migraine preventive agents to women of reproductive age, ensuring potential risks are minimized.
Unexpected Pregnancy Protocol: Women should be informed that if they become unexpectedly pregnant while on migraine preventive treatment, they should immediately discontinue the medication and promptly consult their physician.
Open Communication: Proactive planning is essential to balancing effective migraine management with maternal and fetal safety.
Special Considerations for Women Planning Pregnancy
Women requiring preventive treatment who wish to conceive should be reassured that, in most cases, migraine symptoms improve during pregnancy. However, conception can take months, during which the burden of migraine may remain high, particularly in those with chronic or high-frequency episodic migraine.
Treatment Strategy During Pregnancy Planning
Ideal Scenario: Women planning pregnancy should ideally be free from preventive drugs for many months before pregnancy; however, this is rarely feasible.
Practical Approach:
- Non-pharmacological options (lifestyle interventions, neuromodulation) should be prioritized
- When pharmacological prevention is necessary, agents with shorter half-life and more favorable safety profile should be preferred (beta blockers, amitriptyline)
- Anti-seizure medications and ACE pathway inhibitors should be avoided due to first-trimester risks
- Nerve blocks and BTX-A might represent good options
CGRP Pathway Inhibitors: Special Planning Considerations
5 Months
CGRP-mAbs Discontinuation
Should be discontinued at least 5 months before conception due to long half-life (approximately 27-31 days).
3 Days
Gepants Discontinuation
Should be discontinued at least 3 days (5 half-lives) before conception due to shorter half-life.
Gepants vs. CGRP-mAbs for Pregnancy Planning
Gepants have a shorter half-life than CGRP-mAbs, with plasmatic levels declining after a few days. For this reason, gepants might be more suitable than CGRP-mAbs in women who are planning pregnancy and need migraine-specific preventive treatment. However, contraception is still recommended, and treatment should be discontinued at least 3 days prior to conception.
Assisted Reproductive Technology Consideration
Women with migraine with aura referred to assisted reproductive technology should be warned against the risks of migraine worsening associated with those procedures.
Conclusions and Clinical Implications
Migraine management in women during pregnancy, breastfeeding, and pregnancy planning requires a careful balance between maternal well-being and fetal or infant safety. An individualized approach is crucial, considering the complexities of treatment in this population.
Key Clinical Takeaways
Risk Awareness
Migraine is associated with adverse events during pregnancy, including preeclampsia, stroke, and preterm birth. Women with migraine, particularly those with aura, require careful monitoring throughout pregnancy.
Treatment Hierarchy
Non-pharmacological interventions should be prioritized due to their favorable safety profiles. These include lifestyle modifications, complementary therapies (cognitive behavioral therapy, mindfulness, yoga, acupuncture), and when available, non-invasive neuromodulation.
Pharmacological Options
Pharmacological treatments, reserved for severe cases, must be selected with caution:
- Acute Treatment: Acetaminophen as first-line, NSAIDs during second trimester only, sumatriptan as third-line option
- Prevention: Beta-blockers as first-line, amitriptyline as alternative. Valproate and topiramate must be avoided due to teratogenicity
Newer Treatments
The safety data on newer migraine-specific treatments, particularly CGRP pathway inhibitors, remain limited, necessitating extreme caution. These should be avoided during pregnancy and breastfeeding. For women planning pregnancy, CGRP-mAbs require 5-month discontinuation before conception, while gepants need only 3 days.
Multidisciplinary Approach
Given the complexities of migraine management in this population, a multidisciplinary approach involving neurologists, obstetricians, and pediatricians is important. Better education of primary care physicians and women's health providers is advisable, as most cases are managed in primary care.
Public Health Implications
- Most acute and preventive migraine treatments are contraindicated or require caution during pregnancy
- Non-pharmacological treatments are first-line options during pregnancy
- Pharmacological treatments should be used cautiously based on known safety profiles
- Drugs targeting CGRP lack sufficient safety data in pregnancy and breastfeeding, necessitating careful planning for women of reproductive age
Remember: Untreated Migraine Has Consequences
It is important to emphasize that undertreatment of migraine not only results in persistent pain and reduced quality of life, but also increases maternal psychological distress, which has been associated with adverse neurodevelopmental outcomes in offspring. Disabling migraine should not be left untreated.
Important Medical Disclaimer
This information is for educational purposes only and should not replace professional medical advice, diagnosis, or treatment. Always consult with a qualified healthcare provider before making any decisions about migraine treatment during pregnancy, breastfeeding, or when planning pregnancy. Individual responses to treatments may vary, and patients should ensure proper screening and counseling before use.
References
- Ornello R, Maassen van den Brink A, Puledda F, et al. Migraine management during pregnancy, breastfeeding and in women planning pregnancy. Cephalalgia. 2025;45(11):1-21.
- Lipton RB, Bigal ME, Diamond M, et al. Migraine prevalence, disease burden, and the need for preventive therapy. Neurology. 2007;68:343-349.
- Afridi SK, Dassan P. Special considerations in migraine during pregnancy and lactation. Handb Clin Neurol. 2024;199:257-263.
- Puledda F, Sacco S, Diener HC, et al. International Headache Society global practice recommendations for the acute pharmacological treatment of migraine. Cephalalgia. 2024;44:3331024241252666.
- Puledda F, Sacco S, Diener HC, et al. International Headache Society global practice recommendations for preventive pharmacological treatment of migraine. Cephalalgia. 2024;44:3331024241269735.
- Phillips K, Clerkin-Oliver C, Nirantharakumar K, 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.
- Purdue-Smithe AC, Stuart JJ, Farland LV, et al. Prepregnancy migraine, migraine phenotype, and risk of adverse pregnancy outcomes. Neurology. 2023;100:e1464-e1473.
- Bandoli G, Baer RJ, Gano D, et al. Migraines during pregnancy and the risk of maternal stroke. JAMA Neurol. 2020;77:1177-1179.
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