How to Plan for Pregnancy When You Have Migraine

Choosing if and when you want to have children is one of life’s biggest decisions. Your career path, relationship status, financial health, and long-term goals all factor into the equation.

For women living with migraine, the decision can be even more complex. Concerns about the pregnancy, the health of the baby, and the additional daily stressors of living with a debilitating disease can lead many women to question if having a baby is the right choice — now or ever.

Study Shows Fears About Pregnancy With Migraine Are Common

Nearly 1 in 5 women with migraine avoids pregnancy because of her disease, according to a study from 2020. The survey of 607 women with migraine found that the most common reasons women cited for avoiding pregnancy were fears that migraine symptoms would worsen during pregnancy, that having migraine would make their pregnancy difficult, and that migraine medication would affect their child’s development.

But according to Amaal Starling, MD, a neurologist and migraine specialist at the Mayo Clinic in Phoenix, Arizona, although it’s natural to be worried, having a successful pregnancy and delivery while living with the disease of migraine is totally doable.

Having a healthcare provider, whether that’s a neurologist, headache specialist, or primary care doctor, who can collaborate with your obstetrician-gynecologist (ob-gyn) is an important first step, Dr. Starling says.

“The good news is we do have treatment options that can be effective during pregnancy,” Starling says. “It’s just a matter of talking to your healthcare provider about it and making sure they feel comfortable using different treatment options, whether it be for the prevention of migraine or for migraine attacks themselves.”

Understanding how migraine may impact your pregnancy and baby and what your options are for managing migraine during your pregnancy can help you decide what the right choice is for you. Here’s what you should know about planning a pregnancy when you have migraine.

Why You Should Discuss Medication Safety Before Pregnancy

“A large percentage of pregnancies are unexpected or unplanned, and the majority of our patients at the headache clinic are women of childbearing potential,” says Starling.

About half of all pregnancies are unplanned, according to data monitored by the Centers for Disease Control and Prevention (CDC). Unplanned pregnancies can raise risks for mother and child, the CDC notes, through factors like medications a woman might be taking at time of conception or the important role of prenatal nutrition.

“I always discuss the importance of family planning when prescribing any medication that isn’t safe to take during pregnancy to make sure the patient is aware that the medication could be harmful to take during pregnancy or when breastfeeding,” says Starling.

“We’ll talk about what different contraceptive options need to be in place so that we can prevent pregnancy in that situation,” she says.

If a patient is planning on getting pregnant or if that is a possibility, there are many medication options that are still available to use, adds Starling.

RELATED: How to Choose Birth Control When You Have Migraine

The Right Way to Change Migraine Medication for Pregnancy Safety

The key to migraine management leading up to and during pregnancy is consistency; any changes that are made need to be made slowly, says Starling.

“When we’re starting new medication, we usually start at a very low dose, and we increase slowly over time. If we’re deciding to discontinue a medication because someone is planning on getting pregnant, then we will typically reduce it slowly over time,” she says.

It might sound scary to taper off a medication that has been working for you, says Starling. “There are certain medications that are safe to use in the setting of pregnancy, and those that are not. I will always talk to my patients about family planning and reassure them that I will be there to support them through that journey, and that we’ll come up with an alternative plan that will be safe,” she says.

NSAIDs and Opioids May Increase the Risk for Birth Defects or Miscarriage

The use of nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided at certain times during a pregnancy. To cut through any confusion about when they’re safe and when they’re not, Starling suggests that pregnant women avoid them altogether.

NSAIDs include medications such as ibuprofen, aspirin, and naproxen.

A study from 2017 found that women who took NSAIDs and opioid pain medicines during early pregnancy were more likely to have babies with certain birth defects compared with women who took acetaminophen.

NSAID use early in pregnancy is also linked with increased risk of miscarriage, and the risk is higher for women with a lower BMI, according to a 2018 study.

A safety warning issued by the U.S. Food and Drug Administration (FDA) in 2020 recommends that pregnant women avoid NSAIDs at 20 weeks or later because they can result in low amniotic fluid and may cause rare kidney problems in unborn babies.

The FDA advises that women discuss any medication or supplement they are currently taking (or considering taking) with their doctor to make sure it’s safe to take while pregnant or while trying to get pregnant. And NSAIDs should not be taken during the third trimester of pregnancy because they can lead to problems with the baby’s blood supply.

Migraine Symptoms Often Improve With Pregnancy

There is evidence that for many women, migraine can actually improve during pregnancy. Research has found several encouraging trends:

• It was more common for pregnant women with existing migraine to stop having headaches than it was for pregnant women with no previous history of migraine to start having headaches.
• There was a gradual decrease of headache and migraine attacks during pregnancy.
• There was a significant decrease in the duration of headaches during pregnancy compared with headaches before pregnancy.

As many as 50 to 80 percent of pregnant women with migraine have a reduction in migraine attacks during their pregnancy, according to the American Migraine Foundation.

However, for some women, migraine can worsen during the first trimester, says Starling. “A drop or big change in estrogen level can sometimes trigger a migraine attack, and there can be some drastic changes in estrogen early in pregnancy,” she says. That usually levels off and improves in the second and third trimesters, she adds.

Having Migraine Can Raise Your Risk of Certain Complications During Pregnancy

There’s currently no data to suggest that a migraine attack that occurs during pregnancy is harmful to maternal or fetal health, says Starling. “However, in people who have migraine, there is a higher risk of other medical issues, such as preeclampsia and blood clotting disorders,” she says.

Preeclampsia is a complication of pregnancy characterized by high blood pressure and signs of organ damage.

“The migraine attack is not causing those issues; it’s just that having the disease of migraine may increase your risk of having those medical issues during pregnancy,” says Starling.

Signs that a person may be at risk for these complications include migraine symptoms that first appear or that get worse during pregnancy, according to the American Migraine Foundation. If that occurs, you should let your ob-gyn and your headache doctor or primary care doctor know right away.

There Are Ways to Manage Migraine When You’re Pregnant

It's important to consider migraine as a disease with a threshold for attacks — and to know that many different things can change that threshold, says Starling. “There are things that will increase the threshold and make it less likely to have an attack, such as consistent sleep, consistent exercise, consistent eating patterns, preventing dehydration, and stress management,” she says.

There are also medications or procedures that are used as a prophylaxis that can increase that threshold as well, such as a beta-blocker, Botox injections, or a tricyclic antidepressant, says Starling. “In some cases, patients will use birth control medications for hormonal stabilization, and that will help with their migraine attack frequency,” she says.

“When someone is planning for pregnancy, we try to figure out how to reduce these preventive medications without a huge bounce back of migraine attacks, and so we work together to raise the threshold in other ways,” she says.

One way to do that is to maximize nonmedication approaches, says Starling. “That can include biofeedback training, mindfulness training, and relaxation techniques. We could also initiate a lidocaine nerve block,” she adds.

“Once we have a good plan in place and we increase that threshold, then we can start decreasing the birth control and the preventive medication that we are trying to discontinue, because we don’t want to use it in the setting of pregnancy,” says Starling.

“If we need prescription medications, we will pick ones that have less risk and are safer than other medications in the setting of pregnancy,” she adds.

According to a review article published in 2017, beta-blockers like metoprolol and propranolol are the first-line options for migraine prevention in pregnant women. However, they are not risk-free, so their use and the need for prenatal monitoring while taking them should be discussed with your ob-gyn.

Other preventive options that are considered safe to use during pregnancy include the calcium channel blocker verapamil (Calan) and the antihistamine cyproheptadine (Periactin).