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INTRODUCTION Retrospective studies indicate that migraine headaches usually improve (60-70% of female migraineurs) during pregnancy, particularly in the 2nd and 3rd trimester.Improvement is more common in females with menstrual migraine.Approximately 4-8% of women have worsening of migraine headaches during pregnancy.This is more common in females who has migraine with aura.10% of women have onset of migraine during pregnancy.In this case, the headaches usually onset in the first trimester and are more commonly migraine with aura.Migraine may also change during pregnancy from one type to another, i.e. from migraine without aura to migraine with aura. Migraine headaches return to the pre-pregnancy pattern immediately after birth.This is particularly true in patients with menstrual migraine. Prospective studies also suggest an improvement in migraine during the 2nd and 3rd trimester. HORMONAL CHANGES DURING PREGNANCY Pregnancy cause a steady rise in estrogen and progesterone.This may be responsible for the improvement in migraine during the 2nd and 3rd trimester.Estrogen drops rapidly immediately postpartum which may account for the return of migraine headaches at that time. MANAGEMENT OF MIGRAINE DURING PREGNANCY Management of migraine during pregnancy should be largely non-pharmacological.A headache diary can be used to identify and eliminate environmental triggers.Attention should be directed towards good sleep hygeine, nutrition and hydration.Other techniques such as relaxation therapy, massage therapy or biofeedback should be considered. Failing this, some patients will need pharmacologic intervention.Generally speaking, medications should not be given in the first trimester and should be discontinued two weeks prior to delivery.Medications should be prescribed at the lowest effective dose for the shortest time possible. Several drugs used in the acute treatment of moderate to severe headaches are likely safe in pregnancy.The following is a summary: ACUTE THERAPY Analgesics: Aspirin - There is no evidence that aspirin is teratogenic.There are, however perinatal effects.This includes inhibition of uterine contraction, increased maternal and newborn bleeding and narrowing of the ductus arteriosis.Aspirin should not be used in late pregnancy.

Acetaminophen - There are no teratogenic effects and only transient adverse effects on the uterus and platelets. Caffeine - There are no adverse effects on the fetus with low doses of caffeine (less then 300 mg per day).High doses of caffeine may cause low birth weight or spontaneous abortion. NSAIDS - No teratogenic effect is known.NSAIDS, however, can inhibit labour, prolong the length of pregnancy and decrease amniotic fluid.They may also cause premature closure of the ductus arteriorosis or pulmonary hypertension.Use in the3rd trimester should be limited to less than 48 hours. Narcotics - Meperidine and morphine are probably not teratogenic.The main concern with the use of these agents is maternal and neonatal addiction.The duration of use and dose should be minimized.Prolonged use and high doses at term is contraindicated. Antiemetics: Dimenhydrinate- probably not teratogenic. Neuroleptics: Chlorpromazine - most studies indicate that chlorpromazine is safe if used in occasional low doses.There is one report suggesting possible teratogenesicity but this has not been borne out with other studies. Metoclopramide - No teratogenicity has been reported. Prochlorperazine - Occasional reports of congenital malformation exist. Most evidence suggested Prochlorperazine is safe if used in occasional small doses. Ergotamines and Triptans: Ergotamines and triptans are not recommended for use during pregnancy.This is largely due to lack of information about the effects of these drugs on the fetus. (GLAXO WELLCOME PREGNANCY REGISTRY:Glaxo Wellcome has established a pregnancy registry to gather prospective data on exposure to Sumatriptan or Naratriptan during pregnancy.Physicians are urged to report exposed pregnancies and registry forms are available by calling: 1-800-336-2176.) PROPHYLACTIC THERAPY Beta Blockers:There is no evidence of teratogenicity in humans with the use of beta blockers.There may be an increased incidence of intrauterine growth retardation

(IUGR).Propranolol, particularly in doses above 160 mg has been reported to be associated with IUGR, bradycardia and respiratory depression.This should be discontinued two weeks before delivery. Antidepressants: Amitriptyline and Nortriptyline - Limb reduction abnormalities have been reported but not confirmed.These drugs are probably safe for use in pregnancy. REFERENCES Aub M. Migraine in pregnancy. Neurology 1999;53(suppl 1): 826-828. Maggioni F, Alessi C, Maggino T, Zanchin G. Headache during pregnancy. Cephalalgia 1997;17:765-769. Marcus D, Scharff L. Headache during pregnancy and in the postpartum: a prospective study (Abstract). Proc. Am Assoc. Study of Headache 1998: 151-152. Scharff L, Marcus DA. Turk DC. Headache during pregnancy and in the postpartum: a prospective study. Headache 1997;37:203-210. Silberstein SD. Headache and women: treatment of the pregnant and lactating migraineur. Headache 1993;33:533-540. Silberstein SD. Migraine and pregnancy. Neurol Clin 1997;15:209-231. Women's Health Initiatives:Management of migraine throughout the reproductive cycle.Symposium, November 21, 1998; Toronto, ON.