Migraine in women before, during, and after pregnancy

Migraine is the most common type of primary headache in women requiring medical attention,¹ said Professor Jelena Pavlovic, Albert Einstein College of Medicine, NY.

When deciding upon treatment, consider the possibility of a planned or unplanned pregnancy

Men also experience migraine, but overall migraine is more common in women and women have higher rates of most migraine symptoms, greater associated impairment, and higher healthcare resource utilization.¹

Deciding upon which of the many established and new acute and preventive therapies with differing mechanisms of action and differing efficacy and safety profiles to use for each patient can be difficult, especially if there is a possibility of a planned or unplanned pregnancy, said Professor Melissa Lynn Rayhill, University at Buffalo, NY.

In providing guidance on the use of new therapies the American Headache Society states that “the integration of new treatments into clinical practice should be informed by the potential for benefit relative to established therapies, as well as by the characteristics and preferences of individual patients”.²

Severity and frequency of migraine may reflect hormone changes during a woman’s lifespan³

Migraine during pregnancy and postpartum

Changes in hormone levels during a woman’s lifespan can lead to a worsening or improvement in migraine³ (see Estrogen and the patient journey for women with migraine).

Migraine improves in two-thirds of women during pregnancy, usually after the first trimester, said Professor Rayhill. Postpartum, one-third experience headache, which is more common among those with a previous history of migraine and may be aggravated by postpartum-related decreasing estrogen levels.⁴

Migraine often improves during pregnancy⁴

Safety data to inform the use of migraine therapies during pregnancy and lactation are limited, noted Professor Rayhill, and further research is needed to inform therapeutic decision making.⁵ Meanwhile, a narrative review article that classifies migraine therapies into first- second- and third-line options, and “avoid when possible” and “always avoid” categories based on available pregnancy safety information⁶ provides useful guidance.

Migraine vs secondary headache during pregnancy and postpartum

The risk of secondary headache during pregnancy due to pre-eclampsia, stroke, or postpartum angiopathy, is increased in women with a history of migraine

Professor Rayhill highlighted that the incidence of secondary headache increases in pregnancy after 20 weeks’ gestation.⁷ Headaches occurring in pregnant women who do not have a history of headache or who have elevated blood pressure, respectively, are associated with a 5-fold and 17-fold increased risk of secondary headache.⁷

Red flag clinical features of secondary headache during pregnancy include a thunderclap headache, fever, hypertension, and neurologic abnormalities. Causes include pre-eclampsia, stroke, and postpartum angiopathy, which are all increased in patients with a history of migraine.⁸