At the Westport Headache Institute, we often see patients who present with migraine during and after pregnancy. Although it is common knowledge that migraine is associated with changes in hormones, we’ll take a closer look at what specifically happens to migraine during pregnancy and provide some quick tips on what to watch out for. Below, we’ll go through our five most frequently-asked questions about pregnancy and migraine.
1. How does migraine evolve during pregnancy?
During pregnancy, estrogen levels steadily increase, with a peak in the third trimester.
Rising estrogen levels during pregnancy typically correspond with an improvement in migraine. However, a steep decrease in estrogen levels occur after delivery. In the postpartum period, nearly 40% of women experience headaches. Furthermore, migraine intensity and duration often spike during the first week postpartum.
2. Are migraines dangerous during pregnancy?
Retrospective studies have shown that migraine does not have significant negative outcomes on pregnancy. However, untreated migraine severe enough to lead to acute care visits are associated with higher rates of preterm delivery, pre-eclampsia, and low birth weight infants. Furthermore, there are a number of secondary headache causes in pregnancy that can be dangerous, including:
- Pre-eclampsia
- Eclampsia
- Posterior encephalopathy syndrome (PRES)
- Subarachnoid hemorrhage
- Venous sinus thrombosis
- Arterial dissection
- Reversible cerebral vasoconstriction syndrome
It’s important to record migraine characteristics and not dismiss symptoms as a natural consequence of pregnancy. A 2015 systematic review suggested that women with migraine may have higher risks of cerebrovascular or cardiovascular complications of pregnancy, including gestational hypertension, preeclampsia, ischemic stroke, heart disease, and venous thromboembolism.
3. What migraine ‘red flags’ should I watch out for during pregnancy?
Although there are many concerning symptoms that are associated with migraine, there are four ‘Red Flags’ that can signal that a migraine may be caused by a dangerous secondary cause. These red flags are:
- Sudden or unrelenting headache
- Lack of prior headache history
- Hypertension
- Neurologic abnormalities on exam
4. What imaging studies can I take?
There are a number of imaging studies that are used to work up a migraine and rule out a dangerous secondary cause. These imaging tests include brain MRI/MRA head and neck CT/CTAs. It’s important to note that all of these options have their own risks, including ionizing radiation exposure, strong magnetic fields, risk of tissue heating, and in utero exposure to gadolinium. When deciding which imaging modality to use, it’s important to weigh the risks of neuroimaging with risks of a new or worsening headache based on clinical signs and symptoms.
5. What treatment options are available?
Although there are many treatment options for migraine, it’s important to note that some treatments can have adverse effects on babies — for example, third trimester use of ibuprofen can cause impaired renal function and premature closure of fetal blood vessels. Similarly, although acetaminophen is generally considered safe during pregnancy, a recent systematic review have suggested increased risk of neurodevelopmental outcomes, including ADHD, autism spectrum disorder, and lower IQ with prenatal acetaminophen exposure. Nerve blocks have been noted to be safe due to minimal placental transfer, but the gold standard in safety are non-pharmaceutical approaches such as education, relaxation training, and biofeedback.
We hope this quick article can help you make a better informed decision on how to proceed if you have a headache during pregnancy. As always, stay well! – Dr. K