One of the many frustrating things about having migraine disease is the impact it can have on your ability to plan and make decisions about the future. Should you book those expensive concert tickets and risk having to miss out if you had a bad attack on the night? Should you go for that job promotion and risk getting more frequent migraine attacks, if longer hours and more job stress occurs?
And, one of the most life-changing decisions for women, should you have a baby?
In a study of 607 women in the US who had enrolled in a migraine research registry from headache specialty clinics, one in five women said they avoided pregnancy because of migraine.¹ (This compares to 1–3% of people with migraine choosing not to have or have fewer children in general population surveys of migraine).
The women in this study who avoided pregnancy were more likely to be younger, have chronic migraine and also menstrual migraine. The most common reasons given for avoiding pregnancy were believing that migraine would be worse during pregnancy, migraine disability would make pregnancy and raising a child difficult, migraine medications would negatively affect the child’s development and that they would pass on migraine genes to the child. A minority of women thought migraine would cause the baby to have abnormalities at birth.
Are these all good reasons for caution? Firstly, what happens to migraine during pregnancy? Many women find migraine symptoms improve, typically in the second and third trimester. Around 50% of women report an improvement by the end of the first trimester and 80% by the second trimester. This improvement is more likely in women with migraine without aura and possibly those who have a history of menstrual migraine. However, people who have migraine with aura are less likely to improve during pregnancy and rising estrogen levels can even precipitate migraine with aura in women who did not previously experience it. After the baby is born, most people find their migraine pattern reverts to how it was before the pregnancy, although breastfeeding may be protective.
So, for most women, migraine gets better during pregnancy, not worse.
But what about the issue of migraine medications? This is a legitimate concern and women with migraine who are planning to get pregnant are advised to check in with their doctor to talk about migraine management. If taking a preventive medication, this may need to be withdrawn. Anti-seizure medications, particularly sodium valproate (Epilim) and topiramate (Topamax) shouldn’t be used in pregnancy as they can damage the fetus.
There’s no information about the safety of the calcitonin gene-related peptide (CGRP) monoclonal antibodies in pregnancy and it’s recommended to stop taking these for five months before trying to become pregnant. For other preventives, there’s limited information and the benefit of continuing treatment needs to be weighed against the risk of harm. However, given that most migraine disease improves during pregnancy, preventive medications may not be needed and this could be a good opportunity to try coming off them.
Similarly, acute medications may be less necessary, though managing migraine attacks during pregnancy can be challenging. Medicines that are thought likely to be safe include paracetamol, metoclopramide, caffeine (not exceeding 200mg a day) and ondansetron. Non-steroidal anti-inflammatories (NSAIDs) are not to be used in the third trimester and only used in the first or second trimester if the risks and benefits have been carefully considered. There are varying opinions on the use of triptans – discuss this with your doctor. However, occipital nerve blocks can be used in pregnancy. Neuromodulation devices haven’t been tested in pregnant people but are considered likely to be safe. It’s also important to prioritise all the other health behaviours that can help manage migraine – regular sleep, meals and exercise, and managing stress.
So, it’s true that some medications used to treat migraine carry a risk to the fetus, but in most cases, this risk can be minimised or even eliminated. What about migraine causing abnormalities to the child at birth? There is little evidence for this, but migraine is associated with a small increased risk of low birth weight and preterm birth, and hospitalisations, febrile seizures and respiratory distress in the first year of life. There’s a higher risk of the mother with migraine developing pre-eclampsia, a disorder of pregnancy associated with high blood pressure and kidney damage, and other vascular complications. It’s important for pregnant women with migraine to be under the care of a midwife or doctor and have regular blood pressure and symptom monitoring.
As for passing on migraine genes, there’s a definite inherited component to migraine disease. It’s estimated that the child of a person with migraine has a 1.5–4 times increased risk of migraine compared to the general population.² If you’re experiencing severe and disabling migraine, it can be too much to bear to think of passing this on to a child. And it’s undisputable that migraine can impact on a person’s ability to care for children³, participate in social and family life, with flow-on effects on employment and relationships with partners.
For women who have migraine disease and are thinking about becoming pregnant, there are a lot of factors to consider. This is the time to focus on keeping as healthy and rested as possible and to seek advice from your doctor and support from family and friends. Many, many people have one or more parents with migraine but grow up happy and well. And the increase in migraine research means that children born with migraine today will have more treatment options than their parents did. But this can be a heavy decision and every woman has to find what is right for them.
References
- Ishii R, Schwedt TJ, Kim SK, Dumkrieger G, Chong CD, Dodick DW. Effect of Migraine on Pregnancy Planning: Insights From the American Registry for Migraine Research. Mayo Clin Proc. 2020 Oct;95(10):2079-2089. doi: 10.1016/j.mayocp.2020.06.053.
- Grangeon L, Lange KS, Waliszewska-Prosół M, Onan D, Marschollek K, Wiels W, Mikulenka P, Farham F, Gollion C, Ducros A; European Headache Federation School of Advanced Studies (EHF-SAS). Genetics of migraine: where are we now? J Headache Pain. 2023 Feb 20;24(1):12. doi: 10.1186/s10194-023-01547-8.
- Burch R. Epidemiology and Treatment of Menstrual Migraine and Migraine During Pregnancy and Lactation: A Narrative Review. Headache. 2020 Jan;60(1):200-216. doi: 10.1111/head.13665.
