Migraine and pregnancy
If you live with migraine and you're pregnant or planning to be, one of the most common questions we hear is simply: what happens now? The encouraging news is that pregnancy is often a reprieve. Most people with migraine, particularly those whose attacks are tied to their menstrual cycle, notice meaningful improvement, with the majority experiencing fewer and milder attacks by the second and third trimesters as hormone levels stabilize. That said, the first trimester can be a rougher stretch, with more frequent and stronger migraine attacks. But keep in mind, migraine doesn't follow a script. It presents differently for everyone. It's also worth knowing that a new, severe, or unusual headache during pregnancy should never be brushed off as "just a migraine," since pregnancy can occasionally unmask other conditions that deserve prompt evaluation.
Treating migraine during pregnancy presents a unique challenge. Many of the standard therapies used to manage migraine are avoided during pregnancy because they may pose risks to the developing fetus or have not been adequately studied in pregnant women. Common migraine medications such as triptans (Imitrex, Maxalt), gepants (Nurtec, Ubrelvy), and botox have not been tested in pregnant women, and therefore are avoided. NSAIDs are generally avoided during pregnancy because they can interfere with normal fetal development and may increase the risk of complications, especially later in pregnancy. Medications such as topiramate and valproate are generally avoided during pregnancy due to their significant risk of fetal harm. With that said, they are still effective treatments for migraine during pregnancy.
Acetaminophen (Tylenol) is a common first-line option throughout pregnancy. However, for many further treatments may be needed. Neuromodulation has emerged as a popular treatment option during pregnancy because it is both effective and considered safe for many patients. It can be used to treat migraine attacks when they occur and also as a preventive therapy to reduce their frequency. Neuromodulation works by delivering mild electrical or magnetic stimulation to nerves involved in migraine pathways, helping to reduce pain and prevent attacks. Examples of neuromodulation devices include Cefaly, gammaCore, Nerivio, and SAVI Dual.
One treatment option that is particularly valuable during pregnancy is a nerve block. This involves a small injection of lidocaine around specific nerves in the head, such as the trigeminal nerve near the forehead or temple, or the occipital nerves at the back of the head. Because lidocaine acts locally at the injection site rather than throughout the body, it can provide targeted pain relief and is generally considered a relatively safe option during pregnancy. It's a quick, well-tolerated, in-office procedure, and it can be used both to break an active attack, including stubborn, prolonged migraines that haven't responded to other measures, and as a bridge to reduce how often attacks strike.
Above all, if migraine becomes difficult to manage during pregnancy, it is important to have an open discussion with your headache provider and your OB/GYN, and ideally before conception whenever possible. Reviewing your medications and treatment options in advance allows for a thoughtful, proactive plan rather than making changes during pregnancy when symptoms arise. Keeping your obstetric team informed ensures that everyone is aligned on the safest and most effective treatment strategy throughout each stage of pregnancy. Are your migraines becoming difficult to manage during pregnancy? Or are you considering pregnancy and concerned about how migraine may affect you during that time? Click here to schedule a consultation to discuss your options and develop a personalized treatment plan.