Did you know that about one in five women with migraine avoid pregnancy out of fear of migraine worsening, pregnancy complications, or adverse effects of medications on the growing fetus?

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However, it is important to know that migraine improves during pregnancy for most women. Although migraine is associated with a higher risk of some pregnancy complications such as hypertensive disorders of pregnancy, migraine is not a contraindication to pregnancy.

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A lot of other factors come into play too. When considering pregnancy, it can be helpful to discuss your individual potential risks, symptoms to look for, and scheduled screening/monitoring of pregnancy with your obstetrician and your headache doctor. 

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Although some migraine treatments must be avoided in pregnancy due to safety concerns for the fetus, there are treatment options in pregnancy.  

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There are many women’s health considerations related to migraine, and hormonal fluctuations are common triggers of migraine. As a result, many fertility medications can lead to a worsening in migraine attacks. In vitro fertilization and embryo-transfer treatment are also associated with headaches, and more so in women with a history of migraine. To date, there is not much data on the management of headaches and migraine worsening associated with assisted reproductive technology (ART), but it is currently being studied. 

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Since the nervous system starts developing very early in pregnancy, often before you might know you are pregnant, it is recommended to start prenatal vitamins and folic acid supplements as soon as you start pregnancy planning. Make sure you pick a prenatal vitamin with enough folic acid, 400mcg daily. Folic acid is a B vitamin that is necessary to the development of the nervous system.  

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Your history of migraine should be part of the pregnancy planning discussions you have with your doctors. The safety in pregnancy of your current migraine medications needs to be assessed. Some medications can negatively affect your baby early after conception before you even know about your pregnancy, and  it is important to stop taking these medications early in pregnancy planning. It is currently recommended to stop the new CGRP monoclonal antibodies (erenumab/Aimovig, fremanezumab/Ajovy, galcanezumab/Emgality) six months before conception. Other preventive medications such as topiramate or venlafaxine do not have to be stopped well in advance, but it is important to plan as early as possible to plan a transition to other safer preventive options in case your migraine attacks worsen as you stop your current preventive options. Not all headache and pain doctors perform Botox injections during pregnancy, so it needs to be discussed in advance too. 

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Even though most women have an improvement in their migraine attacks during pregnancy, planning a pregnancy can be challenging, and some preventive medications have to be transitioned to ones that are safer in pregnancy. Some acute treatments need to be avoided too. For example, nonsteroidal anti-inflammatory drugs like ibuprofen are not safe in the first and third trimester of pregnancy. Since ART is associated with worsening of migraine, it may warrant an increase in preventive treatments while being mindful of safety in pregnancy. Acute and rescue treatments are particularly helpful during this potentially challenging time. In general, the acute and rescue treatments you take when trying to get pregnant must be safe in pregnancy. However, if you get your periods and confirm you are not pregnant, you will have most of the regular treatment options available to you for a few days to break the headache. 

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