Treating Acute Migraine During Pregnancy: The Need for Guidelines
Treating migraine during pregnancy remains a challenge owing to concerns regarding fetal exposure and a lack of guidelines.
Pregnant women presenting with migraine to acute care settings were found to be treated with therapeutic agents ranging from safe and effective medications to others with unclear efficacy and potential teratogenicity, with some low-risk proven drugs prescribed infrequently, according to a study published in Headache.
Treating migraine during pregnancy — a condition which, if left untreated, may affect maternal and fetal health — remains a challenge owing to concerns regarding fetal exposure and a lack of guidelines.
Researchers performed a retrospective medical chart review to examine choice and sequence of medications by practitioners treating pregnant women who presented to a single-center emergency department (ED) with migraines between 2009 and 2014.
A total of 72 patients (median age, 29; 40% black; 35% Hispanic) treated for migraine with ≥1 pain medication were included in the study, with 18 women (25%) treated in the ED and released and 54 women (75%) admitted as inpatients. Of study participants, 7 (10%) were in their first trimester, 28 (39%) were in their second trimester, and 37 (51%) were in their third trimester. Of the 72 patients included in the review, 34 (47%) presented to the ED with status migrainosus, and 29 (40%) reported experiencing auras. A total of 23 patients (32%) reported not using acute medications before arriving at the ED and 40 women (56%) had taken acetaminophen at home.
The median number of treatments per patient was 4 (interquartile range [IQR], 2 to 8) and median treatment duration while in the hospital was 23 hours (IQR, 5 to 45 hours); the most frequently prescribed medications were metoclopramide (53 women; 74% of patients; 95% CI, 62-82%) and acetaminophen (50 women; 69%; 95% CI, 58-79%). Diphenhydramine was given to 44 of 53 women who were prescribed metoclopramide (81%; 95% CI, 71-91%). The most frequently prescribed medication as initial treatment was acetaminophen, given to 38 of 72 patients (53%), followed by metoclopramide, given to 18 of 72 patients (25%). Metoclopramide was prescribed as second- or third-line treatment in 25 of 72 patients (35%).
Other treatments administered included butalbital and opioids for 35% and 30% of patients, respectively. These treatments were prescribed as second- or third-line treatments to 29% of participants. Intravenous fluid boluses were administered to 38% of patients, and intravenous magnesium to 24% of patients. Peripheral nerve blocks were performed in 6% of patients. None of the included patients were given triptans or non-steroidal anti-inflammatory drugs.
Study limitations include a small sample from a single center and possible skewing toward patients more refractory to treatment.
“These results indicate a need for developing guidelines and protocols to standardize acute treatment of migraine in pregnancy,” concluded the authors. They noted that several pharmacologic and non-pharmacologic therapies considered safe and effective were not prescribed in this patient population.
Dr Robbins has received compensation for serving as a section editor for Current Pain and Headache Reports; received book royalties from John Wiley & Sons; and was a site principal investigator for a clinical trial funded by eNeura, Inc., for which funds went directly to his institution.
Hamilton KT, Robbins MS. Migraine treatment in pregnant women presenting to acute care: a retrospective observational study [published online November 7, 2018]. Headache. doi:10.1111/head.13434