Migraine during pregnancy/following childbirth

Patients of childbearing age who are on acute and / or prophylactic medication for the management of migraine should be warned about the potential for teratogenic effects and / or developmental delay and should be on appropriate contraception.

Patients should have pre-conception counselling so they can make informed choices. This can be undertaken both in primary and secondary care.

Where possible, medications should be withdrawn and non-drug therapies for migraine should be used prior to conception.

The following table gives advice on the safety of acute and preventative treatments during pregnancy.

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Pre- Conception Counselling
Medications should be stopped prior to conception where possible. Where a woman makes an informed decision to continue with medication, use the lowest possible dose.
		Pregnancy
Non-drug strategies		Risk factor management; Avoid Triggers Avoid Medication Overuse Avoid Excessive Caffeine Early Treatment of Nausea
Sumatriptan		Avoid Medication Overuse (limit use to 2 days/ week)
Paracetamol		Avoid Medication Overuse
Ibuprofen		Avoid from 20 weeks onwards
Amitriptyline		Widely used. No reports of limb deformities at low doses.
Propranolol		Risk of neonatal bradycardia and hypoglycaemia in 3rd trimester.
Topiramate		Risk of foetal malformation. Reduce by 25mg/ week. Stop at least one week prior to conception. If unexpected pregnancy, reduce and stop as soon as possible.
Candesartan		Risk of harm. Reduce by 4mg / week. Stop at least one week prior to conception.
Acetazolamide (for IIH)		Risk of Teratogenicity. Stop prior to conception.
Magnesium Supplements		Low dose oral supplementation
Indometacin		Avoid from 20 weeks: use lowest dose possible under direction of specialist if no alternatives available.
Safe to use Caution Ideally avoid, some cases may merit discussion with expert. Sodium valproate for headache is contraindicated in women of childbearing potential.
Resources	BUMPS - Best Use of Medicines in Pregnancy NIH Drugs and Lactation Database (LactMed)

If red flags are identified in the history or examination, women should be referred urgently to secondary care for further assessment. For women in the third trimester, it is imperative to exclude pre-eclampsia as a cause for new unremitting headache.

Safety of investigations for headache in pregnancy
CT brain (with or without contrast)		The risk of neonatal thyroid dysfunction with iodinated contrast not proven in vivo. Suitable abdominal protection advised.
Non-contrast MRI		Safe
Lumbar puncture		Safe where brain imaging allows.
Note: Women in the puerperium should be investigated as for the non-pregnant population.

Acute treatments for migraine during pregnancy
		Pregnancy	Lactation
Painkillers	Paracetamol	Safe	Safe
	Aspirin	Avoid Treatment doses	Avoid in breastfeeding
	Ibuprofen	Avoid from 20 weeks	Safe in lactation
	Codeine	Safe: not recommended first line	Potential adverse events in the infant
Anti-emetic	Metoclopramide	Used widely	Used widely
	Prochlorperazine
Triptans	Sumatriptan	Safe	Safe
	Other Triptans	Insufficient safety data	Insufficient safety data
For all acute treatments, use should be limited to no more than 2 days per week to prevent development of Medication Overuse Headache.
Resources BUMPS - Best Use of Medicines in Pregnancy NIH Drugs and Lactation Database (LactMed)

Paracetamol is commonly used in all stages of pregnancy and is considered safe for occasional use. Regular paracetamol (regular use for several weeks or longer) use has been weakly associated with neurodevelopmental abnormalities. Paracetamol is excreted in low quantities in breast milk but is considered safe.

Aspirin at high doses (above 150mg) should be avoided both in pregnancy and lactation due to the risk to the infant. Low doses of aspirin (up to 150mg per day) have been shown to be safe.
It is uncertain as to whether ibuprofen taken in the early stages of pregnancy contributes to a higher rate of miscarriage. Ibuprofen therefore may be considered under specialist recommendation up until week 20. Ibuprofen is associated with premature closure of the ductus arteriosus in later stages of pregnancy, so it is recommended to avoid from week 20 onwards. There is also evidence to show adverse effects on labour in humans. Ibuprofen is excreted into breast milk but has not been associated with a high risk of complications and is considered safe.

Codeine is safe in pregnancy but should not be used first line due to its adverse effects on the mother. Regular use should be avoided due to the risk of dependency in the infant. Chronic use has been shown to lead to medication overuse headache. Due to the risk of dependency/opioid effects in the infant, codeine use is not recommended in lactation.

Antiemetic medications have been widely used in pregnancy and are considered safe.

Registry data has informed on the use of sumatriptan in pregnancy. A meta-analysis of triptans at all stages of pregnancy failed to show a link between triptan use and major congenital malformation or prematurity. Sumatriptan may be considered in any stage of pregnancy where treatment with paracetamol or ibuprofen fails or is contra-indicated.

Preventative Therapies for Migraine During Pregnancy Most migraine improves after the first trimester and therefore preventative therapies should be avoided where possible. Use lowest effective dose and withdraw in the last weeks of pregnancy Lifestyle factors should be addressed prior to starting medication.
	Max. dose	Pregnancy		Lactation
Amitriptyline	50mg/day	Widely used		Avoid in Premature/ New-born
Propranolol	20mg BD	Risk of foetal bradycardia and hypoglycaemia in 3rd trimester.		Probably safe
Topiramate	AVOID	Risk of foetal malformation		Limited data, potential toxicity
Candesartan	AVOID	Risk of harm		Insufficient data
Non-standard therapies that may be considered in pregnancy.
Low dose aspirin	75-150mg / day		Safe	Use with caution: chance of excretion
GON blocks (methylprednisolone)			Avoid steroids in first trimester: otherwise considered safe. Can be used as lidocaine alone.	Limited data; considered safe
Magnesium supplements	200mg/ day		No evidence of harm at low doses	Considered safe at low doses.
Resources BUMPS - Best Use of Medicines in Pregnancy  NIH Drugs and Lactation Database (LactMed)

Medication overuse, excessive caffeine intake, psychiatric co-morbidity, pain, sleep disturbance and nausea should be adequately addressed prior to starting preventative therapies. Relaxation strategies and regular exercise should be explored.

Amitriptyline is widely used in pregnancy and is considered safe although there have been occasional reports of amitriptyline and congenital malformations, this is not reproduced in the bulk of available evidence.

Propranolol has wide use in pregnancy. Propranolol may cause intrauterine growth restriction (IUGR). Use in the third trimester has been associated with foetal bradycardia and hypoglycaemia. Small amounts are excreted into breast milk, but no adverse effects have been reported.

Prenatal exposure to topiramate has an increased risk of major congenital malformations (OR 2.02, 95% CI 0.97 to 4.21) and it was dose dependent. Cardiac malformations are the most frequent abnormality followed by hypospadias and multiple major congenital malformations. Children exposed to topiramate in utero are at high risk of serious developmental disorders (HR 3.53, 95% CI 1.42 to 8.74 for risk of developing intellectual disability, and HR 2.73, 95% CI 1.34 to 5.57 for autism spectrum disorder).

There is also a risk of low birth weight. It should not be used by women who are breastfeeding as it can be present in breast milk. Topiramate must no longer be prescribed to women and girls unless they fulfil the requirements of a Pregnancy Prevention Programme. As such, women under 55 years of age must use effective birth control throughout treatment and take a pregnancy test prior to starting topiramate. Healthcare professionals should make patients aware of the risks of the use of this medication during pregnancy and complete a risk awareness form. Advice on contraception is available from the Royal College of the Obstetricians and Gynaecologists Faculty of Sexual and Reproductive Healthcare.

For women who may become pregnant, topiramate should only be considered as a prophylactic treatment when:

• other treatment options have been exhausted
• patients are using highly effective contraception

Before commencing treatment women should be informed of:

• the risks associated with taking topiramate during pregnancy
• the risk that potentially harmful exposure to topiramate may occur before a woman is aware she is pregnant
• the need to use effective contraception
• the need to seek urgent advice on migraine prophylaxis if pregnant or planning a pregnancy.

Candesartan may cause complications in pregnancy (teratogenicity, oligohydramnios, IUGR) and should be avoided in pregnancy. No reports describing the use of candesartan in breastfeeding have been found but excretion into human breast milk is expected. There is insufficient data to conclude safety in breast feeding.

The use of methylprednisolone for Greater Occipital Nerve (GON) blocks is usually considered safe however available data are limited. Steroid use early in pregnancy may cause developmental abnormalities but the risk with local administration is less clear. The risk versus benefit of treatment should be assessed and discussed with each patient prior to administration.

There are no licensed magnesium products for use in pregnancy. The available evidence suggests that magnesium is not associated with congenital defects based on a large number of reports. Magnesium supplementation would appear compatible with breastfeeding, although if taken during pregnancy it might delay the onset of lactation. No special precautions are advised in relation to magnesium use in breastfeeding.

Sodium Valproate is contra-indicated in women of childbearing age due to the risk of foetal malformation and poorer cognitive outcomes of children exposed to valproate in utero. Sources of further advice on the prescription of sodium valproate in women who have the potential to become pregnant is available from the MHRA and in SIGN155.

Toolkit on the risks of valproate medicines in female patients:
www.gov.uk/government/publications/toolkit-on-the-risks-of-valproate-medicines-in-female-patients
This website provides guidance for healthcare professionals and patients on prescribing and dispensing valproate.

SIGN 155 clinician guidance SIGN 155 Pharmacological management of migraine (revised May 2026)

SIGN 155 patient guidance SIGN Migraine patient booklet PAT155 (revised May 2026)

BUMPS – Best Use of Medicines in Pregnancy https://www.medicinesinpregnancy.org 

National Maternity Network. Management of Headache in Pregnancy. Guidance developed by Scottish Government ‘Best Start’ Obstetric Neurology Working Group https://www.perinatalnetwork.nhs.scot/wp-content/uploads/2023/02/2023-02-21-Headache-in-Pregnancy.pdf

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