Introduction
Migraine is a common primary form of headache (TH), which manifests itself in the form of repeated attacks, often accompanied by nausea, vomiting, photo- and phonophobia.
The prevalence of migraine, according to various estimates, ranges from 2.6% to 21.7%, and the average rate is 14.7% [1]. In Russia, the prevalence of migraine reaches 20.8%, which is approximately more than 30 million people [2]. The prevalence of migraine in women is more than 2 times higher than that in men, and the highest prevalence of migraine within the female population occurs during reproductive age [3]. For this reason, issues of tactics for managing patients with migraine during pregnancy are of high relevance. Issues of pregnancy planning, as well as rules for taking medications for pain relief and approaches to preventive treatment of migraine during pregnancy are discussed very often.
The course of migraine during pregnancy
In 50–70% of women during pregnancy, migraine without aura improves [4]. Migraine attacks become mild, extremely rare, and in most patients in this group the migraine completely disappears. Improvement occurs after the first trimester, starting from the 12th–14th week. pregnancy. This is due to the fact that by the beginning of the second trimester, the level of estrogen stabilizes and begins to increase, and its fluctuations stop (Fig. 1). Migraine with aura stops less often during pregnancy, in approximately 40% of patients.
At the same time, if headache persists during this period, it is necessary to carry out differential diagnosis and determine the form of headache. Alarming symptoms during pregnancy are:
the appearance of a new, unusual headache;
a sharp increase in migraine attacks;
the addition of new, unusual symptoms of hypertension, including visual impairment, sensitivity, aphasia, paresis of the limbs;
the appearance of migraine aura in patients with previous migraine without aura;
increased blood pressure during hypertension;
convulsions.
The presence of active migraine during pregnancy does not affect the course of pregnancy itself and the development of the fetus, but increases the risk of preeclampsia and gestational hypertension. Moreover, the persistence of active migraine, especially migraine with aura, during pregnancy increases the risk of acute cerebrovascular accidents (ACVA) by 15–17 times [5]. The prevalence of stroke during pregnancy and the early postpartum period is 34.2 cases per 100,000 births [5].
Treatment of headaches in pregnant women with migraine
This disease has hereditary roots. It is mainly found in females aged at least 20 years. Mainly one part of the head hurts. Moreover, the pain does not go away for at least 4 hours, maximum 3 days. At the same time, light and loud sounds are poorly tolerated. The person tries not to move, otherwise the pain becomes even stronger.
For most pregnant women, migraine subsides and may return at the end of the lactation period. But rarely in the first trimester there is an increase in migraines. Treatment is carried out mainly with medications. If your doctor prescribed triptans before conception, you should not take them during pregnancy. Paracetamol, which is harmless to expectant mothers, can help. The attacks will most likely disappear after the 20th week of pregnancy. Eliminate foods that aggravate migraine headaches from your diet. These are chocolate, bananas, sausage, etc.
Stopping attacks
The selection of drug therapy for patients with migraine during pregnancy poses significant difficulties. The severity of migraines can be especially high during the first trimester. Full-blown, unrelieved migraine attacks are often accompanied by nausea, vomiting and lead to unnecessary suffering and dehydration, especially in patients suffering from early toxicosis. Despite the desire to avoid taking medications (especially in early pregnancy) to minimize the risk of fetal developmental disorders, many patients with hypertension begin to take analgesics uncontrollably. Therefore, the importance of preliminary counseling and education of patients on the proper control of hypertension cannot be overemphasized.
Non-pregnant women are recommended to take medications to relieve migraine attacks as early as possible, no later than 1 hour after the onset of the attack. This approach allows you to speed up relief and completely stop a migraine attack in a short time. Pregnancy is the only period in a woman’s life when this recommendation can be temporarily ignored. For patients seeking to minimize drug use, a stepwise approach may be recommended, in which treatment of mild to moderate attacks begins with non-drug methods.
If the patient decides not to use analgesics, control of nausea becomes a priority to avoid dehydration. Patients should avoid strong odors and drink more fluids, such as juices diluted 1:1 with water. Feelings of nausea can also be reduced by eating easily digestible foods, such as crackers, applesauce, bananas, rice, and pasta. Metoclopramide or ondansetron can also be used [6].
Neurostimulation methods play a major role in non-drug approaches to the treatment of migraine. The only device registered in Russia for non-invasive transcutaneous stimulation of the supraorbital nerve - Cefaly (Cefaly®) - is specially designed for the treatment of migraines and can be a good alternative to medications for relieving migraine attacks. Using the Cefaly device at the very beginning of an attack allows you to reduce the intensity of headaches and in some cases completely stop the attack. Thus, the intensity of migraine pain decreases by 4.3 points after 1 hour [7]. Cefaly can also be used in conjunction with pain medications to increase their effectiveness.
Despite the fact that, in general, paracetamol is less effective for relieving an acute attack of migraine than acetylsalicylic acid and nonsteroidal anti-inflammatory drugs (NSAIDs), its safety during pregnancy is higher [6]. Caffeine, which has the ability to enhance the analgesic effect, is an important addition to painkillers. Adding 100 mg of caffeine to the analgesic increases its effect by 1.5 times.
The safety of NSAIDs is controversial [6]. Prescribing NSAIDs in the first trimester may be associated with an increased risk of miscarriage and the development of congenital anomalies. Taking NSAIDs and aspirin in the third trimester can lead to premature closure of the ductus arteriosus
. For these reasons, the use of NSAIDs should be limited to the second trimester. It is especially important to stop taking them after the 32nd week. Taking high doses of aspirin may also increase the risk of bleeding.
Triptans are the most effective analgesics for the relief of migraine attacks. The safety of triptans during pregnancy is assessed through pregnancy registries, where a huge amount of data has now been accumulated for sumatriptan, for example. Despite the prohibition of its use during pregnancy indicated in the official instructions for the use of sumatriptan, there is no evidence of an increased risk of congenital malformations when taken by pregnant women [8]. Patients who took triptans in early pregnancy (without knowing they were pregnant) should be advised that the likelihood of adverse effects of this drug on the fetus is extremely low. Women who experience severe, disabling migraine attacks that cause vomiting may be advised to use triptans during pregnancy. To date, this information has not been included in official recommendations for the treatment of migraine, but the safety of sumatriptan is confirmed by the analysis of a huge number of observations and expert recommendations.
It should be borne in mind that the safety of triptans varies. Sumatriptan, as the most hydrophilic of the triptans, has difficulty penetrating the placental barrier, while other triptans (including eletriptan) are lipophilic.
Prednisolone can only be used as an “ambulance” remedy in the event of a prolonged and severe migraine attack [9]. The use of prednisolone is preferable to dexamethasone, since the latter penetrates the placenta better. Nuchal nerve blocks with lidocaine, bipuvacaine and/or a corticosteroid can be used as an ambulance to relieve severe attacks.
Relieving headaches in pregnant women with brain tumors
Sometimes a pregnant woman attributes nausea, vomiting and headaches to toxicosis. But extremely rarely these can be manifestations of a tumor. The headache usually appears in the morning and then subsides. There are convulsions, changes in the patient’s character, impaired coordination, and dysfunction of organs (which depends on the location of the tumor formation).
Hormonal changes that occur during pregnancy can trigger the growth of tumors: meningiomas and pituitary adenomas. They are benign in nature, so termination of pregnancy will not be necessary.
Remember that in any case, a positive attitude is an excellent prevention and treatment of diseases!
Preventative treatment
The attending physician must promptly identify the group of patients in whom preventive treatment of migraine will be most successful. While most pregnant women begin migraine remission at the end of the first trimester, others experience migraine remission by the 10th–12th week. Frequent attacks may persist, which will most likely indicate the persistence of headache throughout pregnancy. Refusal to treat such patients can lead to malnutrition, dehydration, the development of affective disorders and a significant decrease in quality of life.
Preventive treatment of migraine is necessary in the following cases:
high frequency of attacks (more than 3 days a week);
the presence of severe or prolonged attacks;
significant disability;
dehydration and malnutrition;
poor response to analgesics.
The current frequency of headaches and the effectiveness of the analgesics used should be monitored using a headache diary. For patients who require preventive treatment, it is necessary to select the optimal combination of drug and non-drug approaches.
There are a number of non-drug methods that can effectively manage hypertension during pregnancy and are an important addition to pharmacological methods; when combined, the amount of drugs used during pregnancy and lactation is reduced. Relaxation techniques, cognitive behavioral therapy and biofeedback can be used during pregnancy.
Trigeminal neurostimulation also plays a major role in the preventive treatment of migraine during pregnancy. Regular use of Cefaly daily for 20 minutes, preferably in the evening, leads to a 2-fold reduction in migraine headache attacks in 38% of patients with episodic migraine and 35% of patients with chronic migraine [10, 11]. The high safety of this method (the probability of adverse events is 2–3%) allows it to be used without fear during pregnancy. It is also important that the Cefaly device has a mild sedative effect [12] and is not prohibited for use during pregnancy.
Information about the safety of drugs is collected through clinical trials of their use in the treatment of other diseases, including mood disorders, cardiovascular diseases and epilepsy. The safety of most drugs during pregnancy has not been directly assessed, but accumulated data have allowed these drugs to be assigned a certain safety category. In addition, the choice of drugs for the treatment of migraine in pregnancy may be based on additional information about the safety of a number of drugs that are used in pregnancy to treat hypertension, depression and epilepsy.
If it is necessary to prescribe drug therapy to reduce migraine attacks, it is recommended to start with the use of β-blockers. Due to its widespread use in the treatment of arterial hypertension during pregnancy, propranolol (anaprilin) is considered the drug of first choice for the preventive treatment of migraine [13]. At the same time, taking β-blockers is associated with a risk of hypoglycemia, hypotension, bradycardia and respiratory disorders in the newborn. The drug should also be used with caution in patients with bronchial asthma, a tendency to arterial hypotension and bradycardia. In the absence of propranolol or if there are contraindications to it, metoprolol can be used. It is recommended to gradually reduce the dose of beta-blockers during the last weeks of pregnancy (starting from the 36th week) and discontinue them at least 2-3 days before delivery.
No adverse effects on fetal development have been demonstrated with the use of calcium channel blockers, but insufficient data and the low effectiveness of verapamil do not allow it to be recommended for widespread use for the preventive treatment of migraine during pregnancy [13].
Lisinopril exhibits a teratogenic effect when used in the 2nd and 3rd trimesters and should be discontinued. Candesartan, which has a mechanism of action similar to lisinopril, should also not be used to treat migraine in pregnant women [14].
Despite the high effectiveness of antiepileptic drugs in the treatment of migraines, their use during pregnancy is prohibited. Valproic acid preparations are absolutely contraindicated during conception and pregnancy due to their teratogenic effect (disrupting the development of the fetal neural tube) and blood clotting disorders in the mother and fetus. In addition, data have accumulated on the possible teratogenic effects (development of hypospadias, cleft lip and palate) of topiramate [14].
Gabapentin has low effectiveness in the preventive treatment of migraine; the safety of its use during pregnancy has been poorly studied. Its use should be stopped in the third trimester due to its possible effect on bone development [6].
Tricyclic antidepressants are highly effective in the preventive treatment of migraine. Amitriptyline is relatively safe during this period and is the second choice drug for the preventive treatment of migraine [6, 13, 15].
The use of the serotonin and norepinephrine reuptake inhibitor venlafaxine in the third trimester increases the risk of developing behavioral syndrome of newborns by 3 times. Symptoms are usually mild in severity.
The safety of botulinum toxin type A preparations for the treatment of migraine during pregnancy has not been studied. At the same time, data have accumulated on the absence of teratogenic and embryotoxic effects of botulinum toxin type A in pregnant women who reported using the drug for various indications [16]. At the same time, the use of botulinum toxin for the preventive treatment of migraine during pregnancy is not recommended.
New drugs for the preventive treatment of migraine - antibodies to calcitonin gene-related peptide - erenumab and fremanezumab have not been studied for use in pregnant women and are not recommended for the treatment of migraine.
In addition to the above medications allowed during pregnancy, various vitamins and minerals can be mentioned. In particular, there is evidence of the benefits of magnesium for the preventive treatment of migraine during pregnancy [13, 15]. Pyridoxine (vitamin B6) at a dose of 80 mg/day alone or in combination with other drugs at a dose of 25 mg/day, for example with folic acid, can have a mild preventive effect against migraine.
Table 1 summarizes the safety data of the main groups of drugs used for the preventive treatment of migraine during pregnancy.
Causes
As noted above, headaches during pregnancy can occur due to increased levels of progesterone in the body. This hormone has a relaxing effect on the uterus and blood vessels, which leads to the appearance of headaches. Other possible reasons:
- fatigue
- noise (listening to music, watching TV)
- stress
- strong odors
- inflammation in the sinuses (frontitis, ethmoiditis or sinusitis)
- food additives in the products you buy in stores (flavor enhancers, flavors, preservatives, etc.)
- hypertension (which was present before or after conception)
- intoxication of the body due to intestinal infectious diseases or even a common cold
- presence of anemia
- long periods of time in a room with low oxygen levels
- lack of water in the body (a pregnant woman sweats during physical activity, drinks little water, etc.)
- hypotension (low blood pressure)
- preeclampsia and eclampsia
- brain tumors
- migraine
- cervical osteochondrosis and muscle spasms of the neck (pain “radiates” to the head)
- rare diseases (encephalitis, meningitis, stroke, ruptured aneurysm)
Eating these foods can cause headaches in a pregnant woman:
- cream, sour cream
- nuts
- citrus fruit
- aged cheeses
- avocado
- bananas
- beans,
- coffee Tea
- chocolate
- soy sauce
- smoked fish
Tension headache
In this case, pregnant women characterize the pain as compressive, there are no peaks or subsidence. Often occurs in the evening. Also accompanied by fatigue, neck or back pain. Diagnosis should include tests for depression and other illnesses. You can take paracetamol to relieve pain. Non-drug methods of therapy and prevention are also relevant.
Cervical osteochondrosis
The headache with this disease is severe. The following symptoms are also likely:
- colored spots before the eyes or “spots”
- dizziness
- noise in the head
- pain in the shoulders and arms
It is important for the doctor to be attentive to the specific medical history of the pregnant woman, to check whether she has other symptoms that appear with a cervical hernia or osteochondrosis. Diagnosis using MRI should be used during pregnancy only if absolutely necessary. If the pain cannot be tolerated, the woman can take paracetamol. For less severe pain, the following remedies are relevant:
- warming with herbal compresses
- collar area massage
- walks in the open air
- gentle manual therapy
Hypertension
This is a persistent increase in blood pressure (BP). The pain is vascular, throbbing. Localized mainly in the occipital zone. Symptoms such as “floaters” before the eyes and dizziness also appear. Sometimes bleeding from the nose may occur. Blood pressure needs to be measured regularly. Non-drug treatment methods are relevant. If the pain is severe and hypertension is confirmed, dopegit or nifedipine is used for treatment in the doses prescribed by the attending physician.
Preeclampsia
As with hypertension, the pain is vascular. But the accompanying manifestations differ:
- loss of consciousness
- convulsions
- swelling
- visual impairment
For diagnosis, you need to measure blood pressure, control edema, and submit urine for a general analysis. The woman is admitted to the hospital and measures are taken to lower her blood pressure. In some cases, emergency delivery is performed.
Anemia
Patients characterize the headache as pressing (if its cause is anemia). Associated signs of the disease:
- general weakness
- chilly feet
- pale skin, etc.
To determine anemia, a pregnant woman donates blood for a general analysis and determination of serum iron. As a treatment, doctors prescribe ferrous iron supplements.
Intoxication of the body
Pain appears along with high body temperature. The pain is diffuse, moderate. Symptoms of the underlying disease also appear. If it is an intestinal infection, there will be stool disturbances. Possible body aches, runny nose, cough, nasal congestion, etc. To confirm the diagnosis, a pregnant woman needs to donate blood for a general analysis. The doctor also collects anamnesis. You can bring down the temperature with paracetamol.
Migraine
The pain is mainly localized on one side of the head, quite intense, pulsating in nature. There may be an aura before an attack. Associated symptoms: photophobia, lacrimation. Taking paracetamol is relevant, and non-drug methods of treating migraine as a cause of headache do not lose their importance.
Tumors (oncological causes)
The pain can be of a completely different nature, in the morning, afternoon or evening. It is accompanied by neurological manifestations. MRI or computed tomography may be used for diagnosis. If a benign tumor is detected, surgery is prescribed after childbirth. If cancer is detected, doctors may advise terminating the pregnancy and treating the tumor with radiation.
Stroke
If the cause of a headache during pregnancy is a stroke, the pain will be diffuse and sharp. Also typical symptoms:
- loss of consciousness
- unsteady gait
- facial asymmetry
- speech disorder
- paralysis
The person is hospitalized, blood pressure is measured for diagnosis, and a CT scan is performed. An emergency delivery is performed and surgery is often required.
Meningitis
This is a rare cause of headaches in pregnant women. The whole head hurts, the pain is characterized as bursting. A symptom typical of meningitis also appears: the patient, lying down, cannot press her chin to her chest. The doctor should look for other signs of illness in the patient and conduct a cerebrospinal fluid analysis. The cause is identified and appropriate therapy is prescribed. These could be detoxifying agents, antipyretic drugs, antibiotics.
