Migraine in Pregnancy

The good news comes with a caveat about aura

NICE's Clinical Knowledge Summary on migraine states the general pattern plainly: "in pregnancy most women will notice an improvement in frequency and severity of attacks". That improvement is usually attributed to oestrogen levels becoming stable rather than cycling, which is also why migraine often worsens again after birth.

The Migraine Trust puts a number on it and specifies who it applies to: studies show that migraine without aura improves after the first three months of pregnancy for about seven in ten women, whereas "if you experience migraine with aura you are more likely to continue to have attacks during your pregnancy". That distinction matters. If you have aura and nothing has improved by 16 weeks, you are not an outlier.

NICE CKS also gives the background prevalence: migraine is thought to affect about 1 in 7 people globally and is two to three times more common in women than men.

Preventive treatment is generally stopped, and not restarted in primary care

This is the clearest medicines change in pregnancy and it is set out in NICE CKS. Preventive treatment "should not be initiated in primary care for pregnant or breastfeeding women or children", because "many preventative drugs have limited evidence of safety or are contraindicated in these groups", and specialist advice is required.

The Migraine Trust's position is the same in practice: it advises that if you are taking preventive treatments you should discuss stopping them with your doctor. Two named examples in the CKS preventive list, propranolol and topiramate, are the drugs most often involved in that conversation, and topiramate in particular is subject to specific regulatory safety requirements for people who can become pregnant. This page names them and gives no doses; if you are on a preventive, the decision to stop, switch or continue belongs with the clinician who prescribed it, ideally before you conceive.

Treating an attack

For acute attacks the Migraine Trust states that paracetamol is considered safe during pregnancy and breastfeeding, that sumatriptan is the preferred triptan in pregnancy and breastfeeding "because there has been more experience of its use", and that aspirin and opiates such as codeine should be avoided during pregnancy and breastfeeding for migraine.

Anti-inflammatories such as ibuprofen sit in a separate category with gestation-dependent advice, and they are one of the drugs where the answer genuinely changes by trimester rather than being a simple yes or no. Ask specifically rather than assuming.

Anti-sickness medicines are often the more useful part of treatment when nausea is the dominant symptom, and NICE CKS lists prochlorperazine and metoclopramide among the anti-emetics used with acute migraine treatment outside pregnancy. Which of these is offered to you in pregnancy is a prescribing decision, so again, no doses here.

The non-drug part that actually helps

Migraine triggers in pregnancy skew heavily towards dehydration, missed meals, disrupted sleep and caffeine changes, all of which pregnancy delivers at once. Nausea in the first trimester means fewer meals; night waking in the third means less sleep; and people often cut caffeine abruptly on seeing a positive test, which is itself a well-recognised headache trigger. Tapering rather than stopping dead avoids that particular avoidable attack. A headache diary, which NICE CKS recommends generally, is more useful in pregnancy than at other times because the triggers are changing month to month.

When a headache in pregnancy is not migraine

This is the part that matters most, because migraine and pre-eclampsia can both present as a bad headache and the management could not be more different.

NICE guideline NG133 lists severe intractable headache and repeated visual scotomata among the features indicating severe pre-eclampsia. In practice, a headache in the second half of pregnancy that is new for you, does not respond to simple painkillers, or comes with visual disturbance, upper abdominal pain, sudden swelling or vomiting is a reason for same-day assessment with a blood pressure check and urine test, not a reason to lie down in a dark room.

Other headache patterns needing urgent assessment are the same ones as outside pregnancy: sudden severe onset reaching maximum intensity within seconds, headache with fever and neck stiffness, headache with new neurological signs, and headache that is consistently worse on lying flat or on coughing. NICE CKS lists admission or referral criteria including suspected serious cause, status migrainosus lasting more than 72 hours, and complications of migraine. Pregnancy also raises the risk of cerebral venous thrombosis, which is uncommon but presents as a persistent, unusual headache.

Aura, migraine and pre-eclampsia risk

Migraine, particularly with aura, is associated with a modestly increased risk of pre-eclampsia. Your midwife will already be assessing pre-eclampsia risk factors at booking under NICE guideline NG201, and migraine with aura is worth mentioning as part of that history so it is recorded and considered rather than discovered later.

After the birth

Attacks commonly return in the first postnatal week as oestrogen falls. The Migraine Trust notes that if you breastfeed you may find it takes longer for attacks to return, because oestrogen levels stay more stable. Any preventive treatment paused for pregnancy is reviewed against breastfeeding rather than simply restarted, so ask for that review to be booked rather than left open.

What to take to the appointment

Two things make a migraine review in pregnancy far more productive. The first is a record of what you were taking before you conceived, including anything bought over the counter, because acute treatment overuse is a common and reversible cause of worsening headache. The second is a simple diary covering four weeks: dates, duration, whether aura was present, what you took and whether it worked. NICE CKS recommends a headache diary generally, and in pregnancy it also documents the improvement, or the lack of it, that decides whether specialist referral is needed.