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  5. 5. Migraine during pregnancy or following childbirth
Important: please update your RDS app to version 4.7.3 Details with newsletter below.

Please update your RDS app to v4.7.3

We asked you in January to update to v4.7.2.  After the deployment planned for 27th February, this new update will be needed to ensure that you are able to download RDS toolkits even when the RDS website is not available. We will wait until as many users as possible have downloaded the new version before switching off the old system for app downloads and moving entirely to the new approach.

To check your current RDS version, click on the three dots bottom right of the RDS app screen. This takes you to a “More” page where you will see the version number. 

To update to the latest release:

 On iPhones – go to the Apple store, click on your profile icon top right, scroll down to see the apps waiting to be updated and update the RDS app.

On Android phones – these can vary, but try going to the Google Play store, click on your profile icon top right, click on “Manage apps and device”, select and update the RDS app.

Right Decision Service newsletter: February 2025

Welcome to the February 2025 update from the RDS team

1.     Next release of RDS

 

A new release of RDS is planned (subject to outcomes of current testing) for week beginning 24th February. This will deliver:

 

  • Fixes to mitigate the recurring glitches with the RDS admin area and the occasional brief user interface outages which have arisen following implementation of the new distributed technology infrastructure in December 2024.

 

  • Capability to embed content from Google calendar, Google Maps, Daily Motion, Twitter feeds, Microsoft Stream into RDS pages.

 

  • Capability to include simple multiplication in RDS calculators.

 

The release will also incorporate a number of small fixes, including:

  • Exporting of form within Medicines Sick Day Guidance in polypharmacy toolkit
  • Links to redundant content appearing in search in some RDS toolkits
  • Inclusion of accordion headers alongside accordion text in search result snippets.
  • Feedback form on mobile app.
  • Internal links on mobile app version of benzo tapering tool

 

We will let you know when the date and time for the new release are confirmed.

 

2.     New RDS developments

There is now the capability to publish toolkits on the web with left hand side navigation rather than tiles on the homepage. To use this feature, turn on the “Toggle navigation panel” option at the top of the Page settings menu at toolkit homepage level – see below. Please note that publication to downloadable mobile app for this type of navigation is still under development.

The Benzodiazepine tapering tool is now available as part of the RDS toolkit for the national benzodiazepine prescribing guidance developed by the Scottish Government Effective Prescribing team. The tool uses this national guidance developed with a wide-ranging multidisciplinary group. This should be used in combination with professional judgement and an understanding of the needs of the individual patient.

3.     Archiving and version control and new RDS Search and Browse interface

Due to the intensive work Tactuum has had to undertake on the new technology infrastructure has pushed back the delivery dates again and some new requirements have come out of the recent user acceptance testing. It now looks likely to be an April release for the search and browse interface. The archiving and version control functionality may be released earlier. We’ll keep you posted.

4.     Statistics

At the end of January, Olivia completed the generation of the latest set of usage statistics for all RDS toolkits. If you would like a copy of the stats for your toolkit, please contact Olivia.graham@nhs.scot .

 

5.     Review of content past its review date

We have now generated reports of all RDS toolkit content that has exceeded its review date by 6 months or more. We will be in touch later this month with toolkit owners and editors to agree the plan for updating or withdrawing out of date content.

 

6.     Toolkits in development

Some important toolkits in development by the RDS team include:

  • National CVD prevention pathways – due for release end of March 2025.
  • National respiratory pathways, optimal cancer diagnostic pathways and cancer prehabilitation pathways from the Centre for Sustainable Delivery. We will shortly start work on the national cancer referral pathways, first version due for release via RDS around end of June 2025.
  • HIS Quality of Care Review toolkit – currently in final stages of quality assurance.

 

The RDS team and other information scientists in HIS have also been producing evidence summaries for the Scottish Government Realistic Medicine team, to inform development of national guidance around Procedures of Limited Clinical Value. This guidance will in due course be translated into an RDS toolkit.

 

7. Training sessions for new editors (also serve as refresher sessions for existing editors) will take place on the following dates:

  • Friday 28th February 12-1 pm
  • Tuesday 11th March 4-5 pm

 

To book a place, please contact Olivia.graham@nhs.scot, providing your name, organisation, job role, and level of experience with RDS editing (none, a little, moderate, extensive.)

 

To invite colleagues to sign up to receive this newsletter, please signpost them to the registration form  - also available in End-user and Provider sections of the RDS Learning and Support area.   If you have any questions about the content of this newsletter, please contact his.decisionsupport@nhs.scot  If you would prefer not to receive future newsletters, please email Olivia.graham@nhs.scot and ask to be removed from the circulation list.

With kind regards

 

Right Decision Service team

Healthcare Improvement Scotland

 

 

5. Migraine during pregnancy or following childbirth

Warning

Background

Primary headache disorders (e.g. migraine, tension type headache) are the most common headache disorders in pregnancy  

Migraine commonly affects women of childbearing age  

Migraine without aura tends to improve as pregnancy progresses but migraine with aura can persist  

Women may develop aura for the first time in pregnancy. The aura may change and become more persistent  

Migraine may change to migrainous aura without headache  

Women may present with headache for the first time during pregnancy.  

Patients of child bearing age who are on acute and / or prophylactic medication for the management of migraine should be warned about the potential for teratogenic effects and / or developmental delay and should be on appropriate contraception. 

Patients should have pre-conception counselling so they can make informed choices. This can be undertaken both in primary and secondary care. 

Where possible, medications should be withdrawn and non-drug therapies for migraine should be used prior to conception. 

The following table gives advice on the safety of acute and preventative treatments during pregnancy.  

Medications should be stopped prior to conception where possible. Where a woman makes an informed decision to continue with medication, use the lowest possible dose.

 

Please note that this table may require scrolling to view all content.

  Max. Dose   Pregnancy
Non drug strategies  

Risk factor management;

Avoid Triggers

Avoid Medication Overuse

Avoid Excessive Caffeine

Early Treatment of Nausea

Sumatriptan 50-100mg prn Avoid Medication Overuse (limit use to 2 days/ week)
Paracetamol 1g prn Avoid Medication Overuse
Ibuprofen 400mg prn Avoid in third trimester
Amitriptyline 50mg /day Widely used. No reports of limb deformities at low doses.
Propranolol 20mg BD Risk of neonatal bradycardia and hypoglycaemia in 3rd trimester.
Topiramate AVOID

Risk of foetal malformation. Reduce by 25mg/ week. Stop at least one week prior to conception.

If unexpected pregnancy, reduce and stop as soon as possible.

Candesartan AVOID Risk of harm. Reduce by 4mg / week. Stop at least one week prior to conception.
Acetazolamide (for IIH) AVOID Risk of Teratogenicity. Stop prior to conception.
Magnesium Supplements 200mg/day Low dose oral supplementation
Indometacin 225mg/day Not recommended in third trimester: use lowest dose possible under direction of specialist if no alternatives available.
Resources

BUMPS - Best Use of Medicines in Pregnancy - https://www.medicinesinpregnancy.org

NIH Drugs and Lactation Database (LactMed)

https://www.ncbi.nlm.nih.gov/books/NBK501922/

 

If red flags are identified in the history or examination, women should be referred urgently to secondary care for further assessment. For women in the third trimester, it is imperative to exclude pre-eclampsia as a cause for new unremitting headache. 

 

Please note that this table may require scrolling to view all content.

Safety of investigations for headache in pregnancy
CT brain (with or without contrast)   Non contrast scan - safe. Very little abdominal radiation exposure. Risk of neonatal thyroid dysfunction with iodinated contrast not proven in vivo.

Non-contrast MRI

Time of flight MRV

  Safe after first trimester. Theoretical risk of foetal hearing damage in 1st trimester. Time of flight MRV does not require the use of IV contrast. The use of Gadolinium contrast should be avoided in pregnancy.
Lumbar puncture   Safe where brain imaging allows.

Note: Women in the puerperium should be investigated as for the non-pregnant population.

Where contrast imaging is performed, appropriate advice about the avoidance of breast feeding for 24 hours afterwards is reasonable.

 

Red flags

Most patients do not have serious secondary headache. Red flags indicate the need for urgent assessment to exclude a secondary cause. The most consistent indicators for serious secondary causes for headache are: 

  1. Thunderclap (sudden onset) headache (consider SAH and its differential) 
  2. New focal neurological deficit on examination (e.g. hemiparesis) 
  3. Systemic features (considering GCA, infection such as meningitis or encephalitis, etc) 

 

Amber flags 

Features that may indicate a secondary cause but may also be seen in primary headaches: 

  1. Changes in headache intensity with changes of posture (upright consider low pressure / headache when lying flat consider high pressure e.g. cerebral venous sinus thrombosis) 
  2. Worsening/Triggering headache with valsalva (e.g. coughing, straining) 
  3. Atypical aura (duration >1 hour or including motor weakness) 
  4. Progressive headache (worsening over weeks or longer) 
  5. Head trauma within the last month 
  6. Previous history of cancer or HIV 
  7. Re-attendance to A&E or GP surgery with progressively worsening headache severity or frequency 

A standard examination in a patient with headache should include blood pressure, fundoscopy and a brief neurological examination looking for new focal neurological deficit.

 

Please note that this table may require scrolling to view all content.

    Pregnancy Lactation
Painkillers Paracetamol Safe Safe
Aspirin Avoid Treatment doses Avoid in breast feeding
Ibuprofen Avoid from 28 weeks Safe in lactation
Codeine Safe: not recommended first line Potential adverse events in the infant
Anti-emetic Metoclopramide Used widely Used widely
Prochlorperazine Used widely Used widely
Triptans Sumatriptan Safe Safe
Other Triptans Insufficient safety data Insufficient safety data
For all acute treatments, use should be limited to no more than 2 days per week to prevent development of Medication Overuse Headache.

Resources

BUMPS - Best Use of Medicines in Pregnancy - https://www.medicinesinpregnancy.org

NIH Drugs and Lactation Database (LactMed)

https://www.ncbi.nlm.nih.gov/books/NBK501922/

 

Paracetamol is commonly used in all stages of pregnancy and is considered safe for occasional use. Regular paracetamol (regular use for several weeks or longer) use has been weakly associated with neurodevelopmental abnormalities. Paracetamol is excreted in low quantities in breast milk but is considered safe. 

Aspirin at high doses (above 150mg) should be avoided both in pregnancy and lactation due to the risk to the infant. Low doses of aspirin (up to 150mg per day) have been shown to be safe. 

Ibuprofen is safe in the first and second trimester but is associated with premature closure of the ductus arteriosus in later stages of pregnancy. There is also evidence to show adverse effects on labour in humans. Ibuprofen is excreted into breast milk but has not been associated with a high risk of complications and is considered safe. 

Codeine is safe in pregnancy but should not be used first line due to its adverse effects on the mother. Regular use should be avoided due to the risk of dependency in the infant. Chronic use has been shown to lead to medication overuse headache. Due to the risk of dependency/opioid effects in the infant, codeine use is not recommended in lactation. 

Antiemetic medications have been widely used in pregnancy and are considered safe. 

Registry data has informed on the use of sumatriptan in pregnancy. A meta-analysis of triptans at all stages of pregnancy failed to show a link between triptan use and major congenital malformation or prematurity. Sumatriptan may be considered in any stage of pregnancy where treatment with paracetamol or ibuprofen fails or is contra-indicated. 

 

Most migraine improves during or after the first trimester and therefore preventative therapies should be avoided where possible. Use lowers effective dose and withdraw in the last weeks of pregnancy. Lifestyle factors should be addressed prior to starting medication.

 

Please note that this table may require scrolling to view all content.

  Max. dose   Pregnancy   Lactation
Amitriptyline 50mg/day Widely used Avoid in Premature/ New-born
Propranolol 20mg BD Risk of foetal bradycardia and hypoglycaemia in 3rd trimester. Probably safe
Topiramate AVOID Risk of foetal malformation Limited data, potential toxicity
Candesartan AVOID Risk of harm Insufficient data
Non-standard therapies that may be considered in pregnancy.
Low dose aspirin 75-150mg / day Safe Use with caution: chance of excretion
GON blocks (methylprednisolone)   Avoid steroids in first trimester: otherwise considered safe. Can be used as lidocaine alone. Limited data; considered safe
Magnesium supplements 200mg/ day No evidence of harm at low doses Considered safe at low doses.

Resources

BUMPS - Best Use of Medicines in Pregnancy - https://www.medicinesinpregnancy.org

NIH Drugs and Lactation Database (LactMed)

https://www.ncbi.nlm.nih.gov/books/NBK501922/

 

Medication overuse, excessive caffeine intake, psychiatric co-morbidity, pain, sleep disturbance and nausea should be adequately addressed prior to starting preventative therapies. Relaxation strategies and regular exercise should be explored. 

Amitriptyline is widely used in pregnancy and is considered safe although there has been occasional reports of amitriptyline and congenital malformations, this is not reproduced in the bulk of available evidence. 

Propranolol has wide use in pregnancy.  Propranolol may cause intrauterine growth restriction (IUGR). Use in the third trimester has been associated with foetal bradycardia and hypoglycaemia. Small amounts are excreted into breast milk but no adverse effects have been reported.  

Exposure to topiramate has an increased risk of oral cleft development in infants (OR 6.2, 95% CI 3.13 to 12.51). Children exposed to topiramate in utero are at high risk of serious developmental disorders (HR 3.53, 95% CI 1.42 to 8.74 for risk of developing intellectual disability, and HR 2.73, 95% CI 1.34 to 5.57 for autism spectrum disorder). It should not be used by women who are breast feeding as it can be present in breast milk. Patients who are using topiramate and who may become pregnant should therefore use highly-effective contraception. Advice on contraception is available from the Royal College of the Obstetricians and Gynaecologists Faculty of Sexual and Reproductive Healthcare,

https://www.fsrh.org/standards-and-guidance/fsrh-guidelines-and-statements/

At the time of writing the MHRA are reviewing the risks of Topiramate in pregnancy. For current contraceptive advice on patients prescribed topiramate check the MHRA website,

www.gov.uk/government/organisations/medicines-and-healthcare-products-regulatory-agency

Candesartan may cause complications in pregnancy (teratogenicity, oligohydramnios, IUGR) and should be avoided in pregnancy. No reports describing the use of candesartan in breastfeeding have been found but excretion into human breast milk is expected. There is insufficient data to conclude safety in breast feeding. 

The use of methylprednisolone for Greater Occipital Nerve (GON) blocks is usually considered safe however available data are limited. Steroid use early in pregnancy may cause developmental abnormalities but the risk with local administration is less clear. The risk versus benefit of treatment should be assessed and discussed with each patient prior to administration. Magnesium supplementation would appear compatible with breastfeeding, although if taken during pregnancy it might delay the onset of lactation. No special precautions are advised.  

There are no licensed magnesium products for use in pregnancy. The available evidence suggests that magnesium is not associated with congenital defects based on a large number of reports. No special precautions are advised in relation to magnesium use in breastfeeding. 

Sodium Valproate is contra-indicated in women of child bearing age due the increased risk of foetal malformation and poorer cognitive outcomes of children exposed to valproate in utero. Sources of further advice on the prescription of sodium valproate in women who have the potential to become pregnant is available from the MHRA and in Sign155.  

Toolkit on the risks of valproate medicines in female patients: 

www.gov.uk/government/publications/toolkit-on-the-risks-of-valproate-medicines-in-female-patients  

This website provides guidance for healthcare professionals and patients on prescribing and dispensing valproate. 

There is limited evidence for the safety of Botulinum Toxin A in pregnant or lactating women. Whilst the risk is likely to be low, treatment using Botox is not recommended in pregnant and lactating women. Practice varies between headache centres varies and some centres do use Botulinum Toxin A in selected patients who are pregnant or lactating. Before considering Botox in pregnancy or lactation the clinician should fully discuss the uncertainty and the potential risks with the patient, written consent should be obtained and the patient should be entered on a pregnancy registry.

 

  1. SIGN 155 Pharmacological management of migraine – updated March 2023; includes clinician and patient guidelines Pharmacological management of migraine (sign.ac.uk) 
  2. BUMPS – Best Use of Medicines in Pregnancy https://www.medicinesinpregnancy.org 
  3. National Maternity Network. Management of Headache in Pregnancy. Guidance developed by Scottish Government ‘Best Start’ Obstetric Neurology Working Group Full text 

 

   gjnh.cfsdpmo@gjnh.scot.nhs.uk

  www.nhscfsd.co.uk

@NHSScotCfSD

Centre for Sustainable Delivery

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Editorial Information

Last reviewed: 11/10/2023

Next review date: 01/04/2025

Author(s): Centre for Sustainable Delivery.