How can you prevent migraines during pregnancy?

Eighteen percent of all women report migraines. Among pregnant migraineurs, 2.5% to 8% reported worsening symptoms. Guidelines recommend considering prophylaxis for nonpregnant patients if they experience at least 3 or 4 prolonged severe attacks per month. Nonpharmacological treatment. Two studies were published together evaluating thermal biofeedback, relaxation training, and physical therapy exercises. The first, a cohort study, showed alleviation of symptoms for 15 of 19 women. The second, a small unblinded RCT, compared 11 women using the combination treatment with 14 control women who received attention from the therapist but no other intervention. Over 72% of the treatment arm improved compared with nearly 29% of the control group. The 30 women (19 from the original cohort and the 11 from the intervention arm of the RCT) were then followed as a cohort for the duration of pregnancy and 1 year postpartum. More than 67% of the patients continued to report a decrease in the frequency and severity of headache. Interpretation of these studies is limited by small sample size and testing in settings with specialized resources that are not found in every community. Pharmacologic agents. Randomized controlled trials have demonstrated that multiple medications have prophylactic benefit in the treatment of nonpregnant patients with migraine. In particular, propanolol, divalproex sodium/sodium valproate, and topiramate have been effective. A single case report on the use of labetalol by a pregnant woman at 28 weeks' gestational age showed that it was effective in reducing the frequency and severity of her headaches after 1 week of use. This improvement persisted until delivery at 38 weeks. Safely in pregnancy. The Food and Drug Administration (FDA) assigns fetal risk categories to all drugs based on controlled studies in humans, animal reproduction studies, and surveillance studies. There are no data about the effectiveness of medications for migraine prophylaxis in pregnancy so one cannot select a specific medication with certainty. However, it may be reasonable to select medications based on both effectiveness for nonpregnant patients and established safety as determined by the PDA's fetal risk summary. The TABLE shows commonly used drugs for prophylaxis of migraine and their pregnancy risk category classification. It should be noted that even if risk has been demonstrated in a medication, not all risks are equal. For example, propanolol is class D because of increased risk for intrauterine growth restriction in the third trimester, while sodium valproate is class D because of known teratogenicity.