Practice 10-Minute Consultation

Managing migraine in pregnancy

BMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k80 (Published 25 January 2018) Cite this as: BMJ 2018;360:k80
  1. Sheba Jarvis, specialist registrar training in endocrinology, diabetes and obstetric medicine1,
  2. Pooja Dassan, consultant neurologist1 2,
  3. Catherine Nelson Piercy, consultant obstetric physician1 3
  1. 1Imperial College Healthcare NHS Trust, London W12 0HS, UK
  2. 2Department of Neurology, Ealing Hospital, London North West Healthcare NHS Trust, Uxbridge Road, Southall UB1 3HW, UK
  3. 3Guy’s and St Thomas’ NHS Foundation Trust, London SE1 7EH
  1. Correspondence to: S Jarvis sheba.jarvis{at}imperial.ac.uk

What you need to know

  • Exclude more serious causes of headache such as cerebral venous thrombosis before confirming a diagnosis of migraine

  • Women with premenstrual migraine and migraine without aura are more likely to see an improvement in symptoms during pregnancy

  • Many therapies for treating and preventing migraines can be safely used in pregnant women

A 36 year old woman who is 17 weeks pregnant with a 15 year history of migraine presents with an episode of a frontal unilateral headache. It is associated with nausea and visual aura consisting of mainly zigzag lines. She says that this headache is similar to her usual migraines, with two other episodes during this pregnancy so far, each lasting for about five or six hours and then resolving. Clinical examination is normal, including blood pressure and urine analysis.

Migraine is one of the commonest neurological complaints in pregnancy, and most affected women either self manage or are managed by non-specialists.1 Many women with a pre-existing history of migraine attacks will see an improvement during pregnancy (particularly those with menstrual related migraine), while those who have migraine with aura are more likely to have an unpredictable course. For a few women, migraine may occur for the first time during pregnancy, which causes anxiety and poses a diagnostic challenge.1 The urgent priority when a patient presents with a headache during pregnancy should be to distinguish primary causes (such as migraine, tension headaches, and cluster headaches) from serious secondary causes. Secondary causes of headaches (such as pre-eclampsia and cerebral venous thrombosis) require urgent assessment and are more likely to occur after 12 weeks gestation (box 1).2

Box 1

Primary and secondary causes of headaches in pregnancy and important clinical features

Primary causes

  • Migraine

  • Tension type headache

  • Cluster headaches (trigeminal autonomic cephalgias)

Secondary causes

  • Hypertension or pre-eclampsia

  • Idiopathic intracranial hypertension

  • Subarachnoid haemorrhage

  • Cerebral venous thrombosis

  • Meningitis

  • Reversible cerebral vasoconstriction syndrome

  • Space-occupying lesions

  • Posterior reversible encephalopathy syndrome …

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