Headache and Migraine in Pregnancy Ottawa Program

Pregnancy and breastfeeding are times of major hormonal and physiologic change, and headache patterns often change as well. Many people worry about which treatments are safe and whether they must “just suffer” during pregnancy or lactation.

The good news is:

• Many people experience improvement in migraine during pregnancy

• Safe treatment options exist

Our clinic helps patients navigate pregnancy and lactation using the best available evidence, balancing symptom control with fetal and infant safety.

How pregnancy affects migraine

• Migraine often improves during pregnancy, especially in the second and third trimesters

• Improvement is most common in people with menstrual-related migraine

• Some people continue to have migraine, and a small number may worsen

Hormonal stability (particularly estrogen) is thought to play a major role.

Migraine during breastfeeding (lactation)

 Migraine patterns vary. Some people remain improved, while others notice recurrence as sleep disruption and hormonal changes occur.

Many migraine treatments are compatible with breastfeeding, and timing doses can further reduce infant exposure.

First-line options for treating acute migraine attacks in pregnancy

Acetaminophen

• First-line acute medication in pregnancy

• Can be used throughout pregnancy

• Often combined with non-medication strategies

Non-medication strategies

Always encouraged, especially in pregnancy:

• Rest in a dark, quiet room

• Hydration

• Cold packs

• Relaxation breathing or mindfulness

Medications used selectively for treating acute migraine attacks in pregnancy

Triptans

• Sumatriptan is the best-studied triptan in pregnancy

• May be used when needed, especially if migraine is severe or disabling

• Use is individualized and based on symptom burden and response

NSAIDs

• May be used with caution in early pregnancy

• Avoid in the third trimester

• Use should always be discussed with a healthcare provider

Medications to avoid for acute treatment of migraine in pregnancy

• Gepants (e.g., ubrogepant, rimegepant)

• Ergot derivatives (e.g., dihydroergotamine)

• Opioids (generally avoided)

Preferred preventive approaches for migraine in pregnancy

Lifestyle and non-drug strategies

• Sleep regularity

• Hydration

• Gentle exercise

• Stress management

Nutraceuticals (commonly used)

Some supplements are often considered:

• Magnesium

• Riboflavin (Vitamin B2)

These are generally regarded as low risk, though dosing and formulation should be discussed.

Prescription preventives for migraine in pregnancy

The two oral preventives with the most widely available safety data in pregnancy are:

• Metoprolol

• Amitriptyline

Preventive medications to avoid for migraine in pregnancy

The following are generally avoided:

• Topiramate

• Candesartan

• Valproate

• Gepants (atogepant)

• CGRP monoclonal antibodies (e.g. erenumab, eptinezumab, fremanezumab, and galcanezumab)

  • These should be stopped at least 6 months before pregnancy

Botox ® for migraine during pregnancy

Botox ® use in pregnancy is an area of growing evidence. It is not routinely started during pregnancy, but may be considered in selected cases where:

• Migraine is severe or disabling

• Other options are ineffective or not tolerated

• The potential benefits outweigh theoretical risks

Important:
Botox ® does not cross the blood–brain barrier, does not seem to cross the placenta, does not circulate systemically in meaningful amounts, and does not suppress the immune system.

Our clinic’s approach

We do offer Botox ® during pregnancy using an individualized, evidence-informed decision-making process.

We:

• Review the available safety data

• Discuss uncertainties openly

• Consider migraine severity and alternatives

• Make decisions collaboratively

Botox ® use in pregnancy is an area of growing evidence. It is not routinely started during pregnancy, but may be considered in selected cases where:

• Migraine is severe or disabling

• Other options are ineffective or not tolerated

• The potential benefits outweigh theoretical risks

Important:
Botox ® does not cross the blood–brain barrier, does not seem to cross the placenta, does not circulate systemically in meaningful amounts, and does not suppress the immune system.

Our clinic’s approach

We do offer Botox ® during pregnancy using an individualized, evidence-informed decision-making process.

We:

• Review the available safety data

• Discuss uncertainties openly

• Consider migraine severity and alternatives

• Make decisions collaboratively

Many acute medications are compatible with breastfeeding, including:

• Acetaminophen

• NSAIDs (e.g., ibuprofen)

• Sumatriptan

In some cases, timing breastfeeding after a dose can further reduce infant exposure. We help guide this on an individual basis.

Not all headache in pregnancy is migraine.

Seek urgent medical evaluation if headache is:

• Sudden and severe (“worst headache of life”)

• New or very different from usual migraine

• Associated with high blood pressure

• Accompanied by visual changes, confusion, weakness, or seizures

• Associated with fever or signs of infection

Eclampsia and preeclampsia

Eclampsia and preeclampsia are serious pregnancy-related conditions that can present with:

• Severe or persistent headache

• Visual disturbances

• Elevated blood pressure

• Neurologic symptoms

Any concern for these conditions requires urgent assessment in the emergency department.

Post-dural puncture headache (PDPH)

Post-dural puncture headache (PDPH) can occur after:

• Epidural anesthesia

• Spinal anesthesia

• Lumbar puncture

Typical features include:

• Headache that is worse when upright

• Improvement when lying flat

• Onset within days of a procedure

This is a treatable condition, often with an epidural blood patch, and should be assessed promptly.