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SIGN decision support

Pregnancy

Pharmacological management of migraine (SIGN)
Healthcare Improvement Scotland

Given that migraine without aura often improves during pregnancy women should aim to stop migraine prophylactic treatments before pregnancy.

Migraine with aura often continues unchanged.

Before commencing treatment, potential harmful effects of therapies need to be discussed with women who are, or may become, pregnant.

Acute therapies

Good practice point tickDue to its safety profile, paracetamol is first choice for the short-term relief of mild-to-moderate headache during any trimester of pregnancy.

Recommendation Consider sumatriptan in all stages of pregnancy. The risk associated with use should be discussed before commencing treatment.

Good practice point tickAspirin, in doses for migraine, is not an analgesic of choice during pregnancy and should not be used in the third trimester of pregnancy.

Good practice point tick Ibuprofen should be used with caution in pregnancy and only up to 20 weeks, if paracetamol or sumatriptan are ineffective in reducing pain.

Good practice point tick Avoid use of rimegepant in pregnancy and breastfeeding.

Preventive therapies

Therapies to avoid during pregnancy or breastfeeding:

  • candesartan
  • atogepant and rimegepant
  • calcitonin-gene-related peptide monoclonal antibodies
  • topiramate
  • sodium valproate
  • flunarazine

Check the Medicines and Healthcare products Regulatory Agency (MHRA) website for current advice.

 

Topiramate

Recommendation Prescribers should be aware that topiramate is associated with an increased risk of serious
developmental disorders, congenital malformations and low birth weight in children exposed to
topiramate in utero. 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 in line with the MHRA Topiramate Pregnancy
Prevention Programme.
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 and stopping topiramate if planning
a pregnancy
• the need to stop taking topiramate (for migraine prevention) straight away if they do become
pregnant and contact their GP.

Good practice point tick A washout period of at least 4 weeks after the last dose of topiramate is advised before trying for a
pregnancy.

Good practice point tick Topiramate should not be used during breastfeeding.

 

Sodium valproate

Good practice point tickAlthough initiation of valproate is not recommended for those under the age of 55, for those who are on it and who fulfil MHRA requirements, inform the patient of the risks to children exposed to valproate in utero and the need to use effective contraception - see CoSRH Guidelines & Statements | CoSRH.