Intended for healthcare professionals

Practice 10-Minute Consultation

Managing migraine in pregnancy

BMJ 2018; 360 doi: (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}

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

  • Pituitary diseases (pituitary adenoma, apoplexy, acute Sheehan’s syndrome, lymphocytic hypophysitis)

  • Other causes of headache—Cervicogenic headaches, medication overuse headaches (patients taking abortive treatment >2-3 times a week), caffeine withdrawal headache, giant cell arteritis (>50 years old), carotid or vertebral dissection, phaeochromocytoma, temporomandibular joint pain, carbon monoxide poisoning, post-epidural puncture headache


What you should cover

Ask about the current pregnancy—date of last menstrual period or dating fetal ultrasound scan to estimate gestation.

Even if the patient has a history of migraine, consider the characteristics of her episodes of migraine before the pregnancy and the nature of her current headache.

  • Characteristics of migraine before the pregnancy:

    • Ask her to describe her previous episodes. Were they associated with prodromal symptoms?

    • Were her attacks related to her menstrual cycle?

    • What medications did she take as prophylaxis or during an acute attack?

  • Nature of the current headache:

    • Assess the onset and character, alterations in headache (such as worsening with posture, coughing, straining, physical exertion, other precipitants)

    • Ask about factors that improve symptoms, such as avoiding motion or darkness

    • Tempo of headache, such as time to maximal onset of pain

    • Are there associated symptoms (including nausea, vomiting, visual symptoms, photophobia, and autonomic features)?

    • Are there any visual changes? Clarify the nature of any aura. Are these similar to the aura associated with her migraine before pregnancy?

    • Are there any other focal neurological symptoms?

    • Are there any cognitive disturbances or changes in behaviour?

    • Is there any recent head trauma?

    • Any fevers, rashes, or neck stiffness?

Box 2 lists the clinical features more likely to be associated with migraine.3

Box 2

Features of headache more likely to be associated with episodic migraine*3

  • Fully reversible episodes of headache lasting 4-72 hours

  • Throbbing, unilateral, or bilateral headaches

  • Recurrent headaches that are moderate to severe

  • Unusual sensitivity to light or sound; nausea and vomiting

  • Aura: symptoms can occur with or without headache and

    • Are fully reversible

    • Develop over at least 5 minutes

    • Last 5-60 minutes

    • Typical aura include visual symptoms (such as flickering lights, spots, lines, partial loss of vision) and sensory symptoms (such as numbness, “pins and needles,” and speech disturbance)

  • Long history of similar attacks

  • Well between episodes

  • No sinister features

  • May be aggravated by certain activities of daily living

  • *Episodic migraine is characterised as <15 headache days (days when a headache occurs) per month.


What you should do


Even though a patient may have a longstanding history of migraine, it is important to rule out any red flag symptoms (box 3)34 and consider any other medical conditions or medications associated with headaches. Measure her blood pressure and conduct urine analysis. Perform a neurological examination, specifically assessing for neck stiffness. Test eye movements, visual fields, and pupillary responses and perform fundoscopy to rule out papilloedema. Refer women with any focal neurological deficits or signs of raised intracranial pressure for urgent intracranial imaging to rule out secondary causes.

Box 3

Red flag symptoms in a patient with headache in pregnancy (adapted from SIGN and NICE guidelines34) and other considerations

Red flag symptoms

  • Sudden onset headache reaching maximal intensity in <1 minute

  • New onset of severe headache or significant changes in headaches

  • Worsening headache with fever, meningism

  • Headache triggered by cough, valsalva, sneezing, or exercise suggestive of raised intracranial pressure (drowsiness, diplopia, papilloedema)

  • Orthostatic headache (changes with posture)

  • New onset focal neurological deficit, cognitive dysfunction, or seizures

  • Recent (within the past 3 months) head or neck trauma

  • Headache with impaired consciousness or personality changes

  • Headache with unusual aura (duration >1 hour or including motor weakness)

  • Progressive headache worsening over weeks or months

  • Visual disturbance or visual field defect

  • Symptoms suggestive of giant cell arteritis (less relevant to women of childbearing age) or glaucoma

Other considerations

  • Is the patient hypertensive?

  • History of neurological conditions, pituitary disease, immunocompromise (such as HIV infection, immunosuppression), malignancy, conditions associated with procoagulable state (such as thrombophilias, antiphospholipid syndrome, polycythaemia, nephrotic syndrome, etc)

  • Is the patient taking a medication that might cause headaches as a side effect (such as calcium channel antagonists for hypertension in pregnancy)?

  • Is there a history of medication overuse, typically opioid analgesia?

  • Is there a family history of intracranial haemorrhage?



When managing a woman with episodic migraine with aura in the context of the second trimester of pregnancy, consider giving the following advice:

  • Migraine may improve during pregnancy (in about 50-75% of women).5 Improvement typically occurs in the second and and third trimesters

  • The normal rise in pregnancy hormones (oestrogen levels can be 100-fold higher than outside pregnancy6) can stabilise migraine without aura but has been associated with increased frequency of migraine with aura.

  • Lack of sleep can precipitate symptoms

  • Treatments that can be used for migraine are summarised in box 4. Advise non-pharmacological measures in the first instance

  • First line pharmacological measures for an acute attack include simple analgesia such as paracetamol.7 Antiemetics can be used to relieve symptoms of nausea and vomiting

  • Women with migraine in pregnancy may be at increased risk of pre-eclampsia, gestational hypertension, arterial and venous thrombosis.89 Explain the symptoms that might signify this and encourage attendance at regular antenatal checks with monitoring of blood pressure and urine.

Box 4

Strategies in the prophylaxis and treatment of migraine in pregnancy

Non-pharmacological strategies58

  • Hydrate with a minimum of 2 litres of water per day

  • Avoid skipping meals

  • Reduce caffeine intake but avoid sudden withdrawal (caffeine withdrawal headaches can occur in patients with consumption of >200 mg/day for >2 weeks, when suddenly interrupted)

  • Sleep hygiene—Avoid bright lights and mobile phone use; have appropriate amount of sleep (7-8 hours a night)

  • Regular exercise

  • Behavioural medicine strategies—Such as biofeedback and relaxation therapy, non-invasive stimulation devices (transcutaneous supraorbital nerve stimulation)10

Treating migraine

  • First line analgesia—paracetamol (acetaminophen)7

    • Avoid opiates—Although they are considered safe, they can exacerbate nausea and reduce gastric motility. Chronic use increases the risk of medication overuse headache

    • If required, consider ibuprofen, although it has less safety data than paracetamol (avoid in third trimester because of risk of premature closure of ductus arteriosus)71112

  • Antiemetics such as prochlorperazine, cyclizine (first line), domperidone, ondansetron, and metoclopramide are safe to use in pregnancy. Avoid long term use of metoclopramide because of its extrapyramidal side effects13

  • Greater occipital nerve block can alleviate pain and reduce the number of headache days and medication consumption14

  • For severe intractable migraine, consider serotonin receptor agonists such as sumatriptan, which has not been shown to be associated with adverse outcome715

  • Do not use topiramate and sodium valproate as they are teratogenic,78 and avoid ergotamines in pregnancy18

Migraine prophylaxis

  • Aspirin 75 mg once a day is often helpful for migraine prevention in pregnancy. Low dose aspirin has been used safely until 36 weeks’ gestation in a recent randomised controlled trial16

  • β Blockers such as low dose propanolol (10-40 mg three times a day) can be used, and once a day preparations can facilitate adherence.15817 Historical concerns about effects on fetal growth from β blockers are from studies which often used higher doses and studied hypertensive mothers or those with cardiac diseases where it is difficult to differentiate the drug effects from underlying condition. Recent studies show use in the first trimester of pregnancy is not associated with a higher risk of specific congenital anomalies18

  • Low dose tricyclic antidepressants such as amitriptyline 10-25 mg taken at night can be considered1119


Education into practice

  • Do you feel confident prescribing treatments for migraine in your pregnant patients?

Professional UK guidelines and resources on headache

How were patients involved in the creation of this article

We sought comments from patients who have had migraine during the pregnancy. Patients felt that, since there are many causes of headache in pregnancy, reassurance from the doctor (after ruling out more serious causes) and a simple explanation about migraine in pregnancy can reduce patient stress. In particular, the patients consulted felt the issue of medication safety in pregnancy was important.


  • This is part of a series of occasional articles on common problems in primary care. The BMJ welcomes contributions from GPs.

  • Contributors: SJ and CNP conceived and contributed to the work. SJ drafted the work, PD and CNP revised it critically. All authors approved the final version for publication and accept full responsibility for the published article. CNP is the guarantor.

  • Competing interests: We have read and understood the BMJ policy on declaration of interests and have no relevant interests to declare.

  • Provenance and peer review: Not commissioned; externally peer reviewed.


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