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Where possible, medications should be withdrawn and non-drug therapies for migraine should be used prior to conception.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

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		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

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