Pregnancy complications and delivery outcomes in pregnant women with severe migraine

Migraine and its Association with Stroke in Pregnancy: A National Examination

Background: Migraine prevalence has been estimated to be as high as 25% during reproductive years. Despite this, and the known significantly lower odds of acute stroke being correctly diagnosed among women versus men, little is known about the migraine-stroke connection in this vulnerable population. Our study seeks to provide a consolidated examination of cerebrovascular and obstetric complications of migraines in pregnant women and to evaluate the role of concurrent comorbidities. Methods: We utilized the 2016-2020 Healthcare Cost and Utilization Project's National Inpatient Sample with the International Classification of Diseases, 10th Revision diagnostic codes to compare pregnant patients with migraines with those without migraines. Multivariable logistic regression was used to examine the incidence of subtypes of stroke while controlling for confounding variables. Results: Overall, 19,825,525 pregnant patients were evaluated; 219,175 (1.1%) had a concomitant diagnosis of migraine. Pregnant patients with migraines were more likely to suffer ischemic (0.1% versus 0.0%) or hemorrhagic stroke (0.3% versus 0.1%). On multivariate analysis, acute ischemic stroke was most strongly associated with migraine with aura (odds ratio [OR], 23.26; 95% confidence interval [CI], 18.46-29.31), followed by migraine without aura (OR, 8.15; 95% CI, 4.79-13.88). Conclusions: Pregnant women with migraine are at a significantly increased risk for both ischemic and hemorrhagic stroke. Pregnant women with migraines should be cautioned that they may be at an increased risk of stroke, particularly if they are experiencing an aura, and encouraged to contact their medical providers to rule out neurological complications.

Prepregnancy Migraine, Migraine Phenotype, and Risk of Adverse Pregnancy Outcomes

BACKGROUND AND OBJECTIVE

Migraine is a highly prevalent neurovascular disorder among reproductive-aged women. Whether migraine history and migraine phenotype might serve as clinically useful markers of obstetric risk is not clear. The primary objective of this study was to examine associations of prepregnancy migraine and migraine phenotype with risks of adverse pregnancy outcomes.

METHODS

We estimated associations of self-reported physician-diagnosed migraine and migraine phenotype with adverse pregnancy outcomes in the prospective Nurses' Health Study II (1989-2009). Log-binomial and log-Poisson models with generalized estimating equations were used to estimate relative risks (RRs) and 95% CIs for gestational diabetes mellitus (GDM), preeclampsia, gestational hypertension, preterm delivery, and low birthweight.

RESULTS

The analysis included 30,555 incident pregnancies after cohort enrollment among 19,694 participants without a history of cardiovascular disease, diabetes, or cancer. After adjusting for age, adiposity, and other health and behavioral factors, prepregnancy migraine (11%) was associated with higher risks of preterm delivery (RR = 1.17; 95% CI = 1.05-1.30), gestational hypertension (RR = 1.28; 95% CI = 1.11-1.48), and preeclampsia (RR = 1.40; 95% CI = 1.19-1.65) compared with no migraine. Migraine was not associated with low birthweight (RR = 0.99; 95% CI = 0.85-1.16) or GDM (RR = 1.05; 95% CI = 0.91-1.22). Risk of preeclampsia was somewhat higher among participants with migraine with aura (RR vs no migraine = 1.51; 95% CI = 1.22-1.88) than migraine without aura (RR vs no migraine = 1.30; 95% CI = 1.04-1.61; p-heterogeneity = 0.32), whereas other outcomes were similar by migraine phenotype. Participants with migraine who reported regular prepregnancy aspirin use had lower risks of preterm delivery (<2×/week RR = 1.24; 95% CI = 1.11-1.38; ≥2×/week RR = 0.55; 95% CI = 0.35-0.86; p-interaction < 0.01) and preeclampsia (<2×/week RR = 1.48; 95% CI = 1.25-1.75; ≥2×/week RR = 1.10; 95% CI = 0.62-1.96; p-interaction = 0.39); however, power for these stratified analyses was limited.

DISCUSSION

Migraine history, and to a lesser extent migraine phenotype, appear to be important considerations in obstetric risk assessment and management. Future research should determine whether aspirin prophylaxis may be beneficial for preventing adverse pregnancy outcomes among pregnant individuals with a history of migraine.

Pre-pregnancy migraine diagnosis, medication use, and spontaneous abortion: a prospective cohort study

BACKGROUND

Migraine is common among females of reproductive age (estimated prevalence:17-24%) and may be associated with reproductive health through underlying central nervous system excitability, autoimmune conditions, and autonomic dysfunction. We evaluated the extent to which pre-pregnancy migraine diagnosis and medication use are associated with risk of spontaneous abortion (SAB).

METHODS

We analyzed data from a preconception study of pregnancy planners (2013-2021). Eligible participants self-identified as female, were aged 21-45 years, resided in the USA or Canada, and conceived during follow-up (n = 7890). Participants completed baseline and bimonthly follow-up questionnaires for up to 12 months or until a reported pregnancy, whichever occurred first. Pregnant participants then completed questionnaires during early (~ 8-9 weeks) and late (~ 32 weeks) gestation. We defined migraineurs as participants who reported a migraine diagnosis or use of a medication to treat migraine. Preconception questionnaires elicited migraine medication use during the past 4 weeks, and SAB on follow-up and pregnancy questionnaires. We used Cox regression models with gestational weeks as the time scale to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for associations among preconception migraine, migraine medication use, and SAB, controlling for potential demographic, medical, and lifestyle confounders.

RESULTS

Nineteen percent of study pregnancies ended in SAB. History of migraine before conception was not appreciably associated with SAB risk (HR = 1.03, 95% CI: 0.91-1.06). Use of any migraine medication was associated with a modest increase in SAB risk overall (HR = 1.14, 95% CI: 0.96-1.36). We observed the greatest increase in risk among those taking migraine medications daily (HR = 1.38, 95% CI: 0.81-2.35) and those taking prescription migraine prophylaxis (HR = 1.43, 95% CI: 0.72-2.84) or combination analgesic and caffeine medications (HR = 1.42, 95% CI: 0.99-2.04).

CONCLUSIONS

Migraine medication use patterns suggesting greater underlying migraine severity were associated with increased risk of SAB. This research adds to the limited information available on the reproductive effects of migraine.

Dihydroergotamine and triptan use to treat migraine during pregnancy and the risk of adverse pregnancy outcomes

Migraine is prevalent during pregnancy. Antimigraine medications such as dihydroergotamine (DHE) and triptans have been associated with adverse pregnancy outcomes in individual studies but lack of consensus remains. We compared the risk of prematurity, low birth weight (LBW), major congenital malformations (MCM), and spontaneous abortions (SA) associated with gestational use of DHE or triptans. Three cohort and one nested-case–control analyses were conducted within the Quebec Pregnancy Cohort to assess the risk of prematurity, LBW, MCM, and SA. Exposure was defined dichotomously as use of DHE or triptan during pregnancy. Generalized estimation equations were built to quantify the associations, adjusting for potential confounders. 233,900 eligible pregnancies were included in the analyses on prematurity, LBW, and MCM; 29,104 cases of SA were identified. Seventy-eight subjects (0.03%) were exposed to DHE and 526 (0.22%) to triptans. Adjusting for potential confounders, DHE and triptans were associated with increased risks of prematurity, LBW, MCM, and SA but not all estimates were statistically significant. DHE was associated with the risk of prematurity (aRR: 4.12, 95% CI 1.21–13.99); triptans were associated with the risk of SA (aOR: 1.63, 95% CI 1.34–1.98). After considering maternal migraine, all antimigraine specific medications increased the risk of some adverse pregnancy outcomes, but estimates were unstable.

Migraine in Women

Migraine is a lifelong condition that disproportionately affects women and, if not effectively managed, can lead to significant disability. It is important for clinicians to have a good understanding of the impact of the hormonal fluctuations that occur throughout a female migraineur's life, so that appropriate, stratified therapies can be implemented. In doing so, whether it is migraine onset at menarche in an adolescent young woman, or migraine worsening in a perimenopausal female migraineur, quality of life can be ensured.

[Migraine in women: clinical and therapeutical aspects]

Migraine is one of the most common neurological disorders, affecting women. Physiological changes in the hormonal status can modulate the functional status of pain and analgesic systems of the brain and, by involving different pathophysiological mechanisms, change the course of migraine. In addition to an analysis of epidemiological data, the review provides current views on the clinical features of the disease in women population at different periods of life, particular attention was focused on menstrual migraine. It has certain features, such as acute and long attacks and treatment difficulties. One of main issues is the use of oral contraceptives in women with migraine according to the ratio of potential benefit to cardiovascular risk. The problems of treatment headaches in pregnant and breastfeeding women are also considered. An influence of migraine on the course and outcome of pregnancy was shown. The authors analysed the results of the studies on the course of migraine during perimenopause and postmenopause and recommendations for women with migraine attacks and climacteric syndrome. The data presented in the review are useful for clinicians, because this information represents new views on pathogenetic mechanisms, clinical features and treatment of migraine in women.

Pregnancy, Birth, Neonatal, and Postnatal Neurological Outcomes After Pregnancy With Migraine

BACKGROUND

Prevalence of migraine is high during the reproductive age. Although migraine often improves during pregnancy, the risk of adverse pregnancy, birth, neonatal, and neurological outcomes in mother and offspring remains poorly understood.

OBJECTIVE

To investigate the associations between maternal migraine and risks of adverse pregnancy outcomes in the mother, and birth, neonatal and postnatal outcomes in the offspring.

METHODS

We used Danish population registries to assemble a cohort of pregnancies among women with migraine and an age- and conception year-matched comparison cohort of pregnancies among women without migraine. The study period was 2005-2012. We computed adjusted prevalence ratios (aPRs) for pregnancy and birth outcomes and adjusted risk ratios (aRRs) for neonatal and postnatal outcomes, adjusting for age, preconception medical history, and preconception reproductive history.

RESULTS

We identified 22,841 pregnancies among women with migraine and 228,324 matched pregnancies among women without migraine. Migraine was associated with an increased risk of pregnancy-associated hypertension disorders (aPR: 1.50 [95% confidence interval (CI): 1.39-1.61]) and miscarriage (aPR: 1.10 [95% CI: 1.05-1.15]). Migraine was associated with an increased prevalence of low birth weight (aPR: 1.14 [95% CI: 1.06-1.23]), preterm birth (aPR: 1.21 [95% CI: 1.13-1.30]) and cesarean delivery (aPR: 1.20 [95% CI: 1.15-1.25]), but not of small for gestational age offspring (aPR: 0.94 [95% CI: 0.88-0.99]) and birth defects (aPR: 1.01 [95% CI: 0.93-1.09]). Offspring prenatally exposed to maternal migraine had elevated risks of several outcomes in the neonatal and postnatal period, including intensive care unit admission (aRR: 1.22 [95% CI: 1.03-1.45]), hospitalization (aRR: 1.12 [95% CI: 1.06-1.18]), dispensed prescriptions (aRR: 1.34 [95% CI: 1.24-1.45]), respiratory distress syndrome (aRR: 1.20 [95% CI: 1.02-1.42]), and febrile seizures (aRR: 1.27 [95% CI: 1.03-1.57), but not of death (aRR: 0.67 [95% CI: 0.43-1.04]) and cerebral palsy (aRR: 1.00 [95% CI: 0.51-1.94]).

CONCLUSIONS

Women with migraine and their offspring have greater risks of several adverse pregnancy outcomes than women without migraine.

Headache and pregnancy: a systematic review

This systematic review summarizes the existing data on headache and pregnancy with a scope on clinical headache phenotypes, treatment of headaches in pregnancy and effects of headache medications on the child during pregnancy and breastfeeding, headache related complications, and diagnostics of headache in pregnancy. Headache during pregnancy can be both primary and secondary, and in the last case can be a symptom of a life-threatening condition. The most common secondary headaches are stroke, cerebral venous thrombosis, subarachnoid hemorrhage, pituitary tumor, choriocarcinoma, eclampsia, preeclampsia, idiopathic intracranial hypertension, and reversible cerebral vasoconstriction syndrome. Migraine is a risk factor for pregnancy complications, particularly vascular events. Data regarding other primary headache conditions are still scarce. Early diagnostics of the disease manifested by headache is important for mother and fetus life. It is especially important to identify “red flag symptoms” suggesting that headache is a symptom of a serious disease. In order to exclude a secondary headache additional studies can be necessary: electroencephalography, ultrasound of the vessels of the head and neck, brain MRI and MR angiography with contrast ophthalmoscopy and lumbar puncture. During pregnancy and breastfeeding the preferred therapeutic strategy for the treatment of primary headaches should always be a non-pharmacological one. Treatment should not be postponed as an undermanaged headache can lead to stress, sleep deprivation, depression and poor nutritional intake that in turn can have negative consequences for both mother and baby. Therefore, if non-pharmacological interventions seem inadequate, a well-considered choice should be made concerning the use of medication, taking into account all the benefits and possible risks.

Pregnancy outcome after anti-migraine triptan use: A prospective observational cohort study

Objective

The objective of our study is to assess the impact of triptan exposure on pregnancy outcome.

Methods

We performed a prospective observational cohort study with 432 pregnant women exposed to triptans and enrolled by the German Embryotox system. Pregnancy outcomes were compared with a migraine and a non-migraine comparison cohort. Primary objectives were major birth defects and spontaneous abortion; secondary endpoints were preterm delivery, birth weight, pregnancy complications and the rate of electively terminated pregnancies.

Results

Compared to a non-migraine cohort the rates of major birth defects (ORadj 0.84; 95% CI 0.4–1.9), spontaneous abortions (ORadj 1.20; 95% CI 0.9–1.7), preterm delivery (ORadj 1.01; 95% CI 0.7–1.5), and preeclampsia (ORadj 1.33; 95% CI 0.7–2.5) were not increased in triptan-exposed pregnancies.

Conclusions

Our findings support the evidence that triptans are not major teratogens. When compellingly needed during pregnancy, sumatriptan as the best studied triptan appears an acceptable treatment option. A detailed fetal ultrasound should be offered in cases of first trimester exposure to less well-studied triptans. Trial registration number in German Clinical Trials Register: DRKS00007660

Migraine and the risk of post-traumatic stress disorder among a cohort of pregnant women

Background

Individually both migraine and post-traumatic stress disorder (PTSD) prevalence estimates are higher among women. However, there is limited data on the association of migraine and PTSD in women during pregnancy.

Methods

We examined the association between migraine and PTSD among women attending prenatal clinics in Peru. Migraine was characterized using the International Classification of Headache Disorders (ICHD)-III beta criteria. PTSD was assessed using the PTSD Checklist-Civilian Version (PCL-C). Multivariable logistic regression analyses were performed to estimate odds ratios (OR) and 95% confidence intervals (CI) after adjusting for confounders.

Results

Of the 2922 pregnant women included, 33.5% fulfilled criteria for any migraine (migraine 12.5%; probable migraine 21.0%) and 37.4% fulfilled PTSD criteria. Even when controlling for depression, women with any migraine had almost a 2-fold increased odds of PTSD (OR: 1.97; 95% CI: 1.64–2.37) as compared to women without migraine. Specifically, women with migraine alone (i.e. excluding probable migraine) had a 2.85-fold increased odds of PTSD (95% CI: 2.18–3.74), and women with probable migraine alone had a 1.61-fold increased odds of PTSD (95% CI: 1.30–1.99) as compared to those without migraine, even after controlling for depression. In those women with both migraine and comorbid depression, the odds of PTSD in all migraine categories were even further increased as compared to those women without migraine.

Conclusion

In a cohort of pregnant women, irrespective of the presence or absence of depression, the odds of PTSD is increased in those with migraine. Our findings suggest the importance of screening for PTSD, specifically in pregnant women with migraine.

Electronic supplementary material

The online version of this article (doi:10.1186/s10194-017-0775-5) contains supplementary material, which is available to authorized users.

Delivery Outcomes of Patients with Acute Migraine in Pregnancy: A Retrospective Study

OBJECTIVE

To describe labor and delivery outcomes in pregnant patients presenting to the hospital setting with an acute severe migraine headache attack earlier in the same gestation.

METHODS

We retrospectively reviewed pregnancy and delivery records from a database of consecutive inpatient neurology consultations for acute headache in pregnant women over a 5 year period.

RESULTS

We identified 86 pregnant women with acute migraine. The mean age was 29.3 (±6.4) years. Nearly half had migraine with aura (35/86 [40.7%]), 12.8% (12/86) had chronic migraine, and 31.4% (27/86) presented in status migrainosus. Complication rates included 54.7%([41/75], 95% CI 29.87, 52.13) for at least one adverse outcome, 28.0% ([21/75], 95% CI 11.78, 30.22) for preterm delivery, 21.3% ([16/75], 95% CI 7.7, 24.3) for preeclampsia, 30.6% ([23/75] 95% CI 13.48, 32.52) for cesarean delivery, and 18.7% ([14/75] 95% CI 6.15, 21.85) for low birthweight.

CONCLUSIONS

Pregnant women seeking treatment for acute migraine headache experienced a higher rate of preterm delivery, preeclampsia, and low birthweight but a lower rate of cesarean delivery than the local and general populations. More than half (54.7% [41/75] 95% CI 29.87, 52.13) of the study patients experienced some type of adverse birth outcome, suggesting that pregnancies in migraine patients presenting to an acute care setting may benefit from more intense surveillance.

Offspring of parents with chronic pain: a systematic review and meta-analysis of pain, health, psychological, and family outcomes

Offspring of parents with chronic pain may be at risk for poorer outcomes than offspring of healthy parents. The objective of this research was to provide a comprehensive mixed-methods systematic synthesis of all available research on outcomes in offspring of parents with chronic pain. A systematic search was conducted for published articles in English examining pain, health, psychological, or family outcomes in offspring of parents with chronic pain. Fifty-nine eligible articles were identified (31 population-based, 25 clinical, 3 qualitative), including offspring from birth to adulthood and parents with varying chronic pain diagnoses (eg, mixed pain samples, arthritis). Meta-analysis was used to synthesize the results from population-based and clinical studies, while meta-ethnography was used to synthesize the results of qualitative studies. Increased pain complaints were found in offspring of mothers and of fathers with chronic pain and when both parents had chronic pain. Newborns of mothers with chronic pain were more likely to have adverse birth outcomes, including low birthweight, preterm delivery, caesarian section, intensive care admission, and mortality. Offspring of parents with chronic pain had greater externalizing and internalizing problems and poorer social competence and family outcomes. No significant differences were found on teacher-reported externalizing problems. The meta-ethnography identified 6 key concepts (developing independence, developing compassion, learning about health and coping, missing out, emotional health, and struggles communicating with parents). Across study designs, offspring of parents with chronic pain had poorer outcomes than other offspring, although the meta-ethnography noted some constructive impact of having a parent with chronic pain.

Migraine and Hormones

This article discusses the role that hormones play in adolescent girls and young women with headaches, which are very common in adolescent girls, in particular, migraine. In many cases, migraine onset may occur shortly around the time of menarche, prevalence of recurrent migraine in this population approaches 15%, and typically the symptoms continue through adulthood. Hormonal changes associated with puberty and the menstrual cycle may significantly influence migraine in young women. This article reviews the following topics: management of menstrually related headaches, changes in ovarian hormones and their relationship to migraine, and oral contraceptives and pregnancy effects on migraine.

Pregnancy outcome following prenatal exposure to triptan medications: a meta-analysis

BACKGROUND

Migraine is a common disorder among women of childbearing age. Triptan medications are effective and commonly used to treat migraines in pregnancy. However, the reproductive safety of this group of drugs has not yet been confirmed. The aim of this study was to determine the reproductive safety of triptan medications by performing a literature review and a meta-analysis.

METHODS

Available publications regarding pregnancy outcomes following prenatal exposure to triptans from 1991 to 2013 were identified and reviewed according to the inclusion criteria. A random-effects meta-analysis model was implemented to combine the available pregnancy outcome data for the exposed and comparison groups.

RESULTS

One case-control study and 5 cohort studies met the inclusion criteria. The included studies provided information on duration of gestation, major congenital malformations, and spontaneous abortions of infants following prenatal triptan exposure. The 6 studies included 4208 infants of women who used sumatriptan or other triptan medications, and 1,466,994 children of women who did not use triptans during pregnancy. No significant increases in rates for major congenital malformations (MCMs), prematurity, or spontaneous abortions were found when comparing the triptan-exposed group to the migraine - no triptans control group (odds ratio [OR] = 0.84 [0.61-1.16]; OR = 0.90 [0.35-2.30]; OR = 1.27 [0.58-2.79], respectively). There were no increased rate of MCMs (OR = 1.18 [0.97-1.44]) or prematurity (OR = 1.16 (0.67-1.99) when the triptan-exposed group was compared with the healthy controls; however, there was a significant increase in the rates of spontaneous abortions (OR = 3.54 [2.24-5.59]). When the migraine no-triptan group was compared with healthy controls, a significant increase in the rates of MCMs was found (OR = 1.41 [1.11-1.80]).

CONCLUSION

The use of triptans during pregnancy does not appear to increase the rates for MCMs or prematurity. The increased rates of spontaneous abortions in the triptan-exposed group and the increased rates of MCM in the migraine no-triptan group require further research.

Peripheral nerve blocks in the treatment of migraine in pregnancy

OBJECTIVE

To describe the use of peripheral nerve blocks in a case series of pregnant women with migraine.

METHODS

A retrospective chart review of all pregnant patients treated with peripheral nerve blocks for migraine over a 5-year period was performed. Injections targeted greater occipital, auriculotemporal, supraorbital, and supratrochlear nerves using local anesthetics.

RESULTS

Peripheral nerve blocks were performed 27 times in 13 pregnant women either in a single (n=6) or multiple (n=7) injection series. Mean patient age was 28 years and gestational age was 23.5 weeks, and all women had migraine, including 38.5% who had chronic migraine. Peripheral nerve blocks were performed for status migrainosus (51.8%) or short-term prophylaxis of frequent headache attacks (48.1%). Before peripheral nerve blocks were performed, oral medications failed for all patients and intravenous medications failed for most. In patients with status migrainosus, average pain reduction was 4.0 (±2.6 standard deviation) (P<.001) immediately postprocedure and 4.0 (±4.4 standard deviation) (P=.007) 24 hours postprocedure in comparison to preprocedure pain. For patients receiving peripheral nerve blocks for short-term prophylaxis, immediate mean pain score reduction was 3.0 (±2.1 standard deviation). No patients had any serious immediate, procedurally related adverse events, and the two patients who had no acute pain reduction ultimately developed preeclampsia and had postpartum headache resolution.

CONCLUSION

Peripheral nerve blocks for treatment-refractory migraine may be an effective therapeutic option in pregnancy.

Headache in pregnancy

PURPOSE OF REVIEW

This article provides an overview of the diagnosis and management of primary and secondary headaches that may occur during pregnancy and postpartum. Headache presenting in pregnancy is of significant concern to the affected woman. Quick and correct diagnosis leads to the optimal management, minimizing risks to the pregnancy.

RECENT FINDINGS

Several strategies have been developed to distinguish secondary headaches that need urgent assessment and management from benign primary and secondary headaches and to minimize the risk of misdiagnosis. Recent guidelines for the drug treatment of headaches are considered in the context of updated information on the safety of drugs in pregnancy and lactation.

SUMMARY

Primary headaches are common and typically improve during pregnancy. Management during pregnancy and lactation is similar to management in the nonpregnant state, with a few exceptions. Secondary causes of headache that are more likely to occur during pregnancy include cerebral venous thrombosis, posterior reversible encephalopathy syndrome resulting from eclampsia, post-dural puncture headache, stroke, and pituitary apoplexy.

Headaches during pregnancy

Among primary headaches, migraine is the form more sensitive to the ovarian hormonal milieu. Migraine without aura (MO) benefits from the hyperestrogenic state of pregnancy and the lack of hormonal fluctuations, while migraine with aura (MA) presents distinctive features. Indeed, a very strong improvement of MO has been documented across gestation, and only a minority of pregnant women still suffers during the third trimester. On the other hand, fewer women with MA report improvement or remission, and new onset of aura may be observed during pregnancy. After delivery, breastfeeding exerts a protective action on migraine recurrence. The persistence of migraine during gestation seems to affect neonatal outcomes, and several studies indicate a link between migraine and an increased risk of developing gestational hypertension/preeclampsia and other vascular complications.

Delivery outcome after maternal use of drugs for migraine: a register study in Sweden

BACKGROUND

The use of drugs for migraine during pregnancy may have adverse effects on delivery outcome, and warnings exist for such drugs regarding use during pregnancy. Most information in the literature concerns triptans.

OBJECTIVE

The aim of the study was to describe the delivery outcome when a woman had used drugs for migraine during pregnancy.

STUDY DESIGN

A register study where exposure for drugs was obtained partly by interview conducted by the attending antenatal care midwife and medical records from antenatal care (1995-2008) and partly by linkage to the Prescribed Drug Register (2005-8).

SETTING

All deliveries in Sweden (1 211 670 women) recorded in the Medical Birth Register with data from antenatal care.

PATIENTS

Women using triptans or ergots during pregnancy were identified and compared with all women who did not use drugs for migraine.

MAIN OUTCOME MEASURES

Pregnancy complications, pregnancy duration and birthweight, neonatal morbidity and mortality, and congenital malformations.

RESULTS

Use of ergots or triptans during early pregnancy (first trimester) occurred in 3286 women with 3327 infants, while use after the first trimester occurred in 1394 women with 1419 infants. Women using such drugs for migraine were older than other women, were more often of parity 1 (no previous infant) and more often had a high body mass index. Women using drugs for migraine had not previously had more miscarriages than expected. There was an increased risk for pre-eclampsia (odds ratio [OR] 1.44; 95% CI 1.17, 1.76). An increased risk for preterm birth was seen after use of drugs for migraine later in pregnancy (OR 1.50; 95% CI 1.22, 1.84). There was no increased risk for stillbirth or early neonatal death. No certain signs of teratogenicity were found for any of the drug types when compared with women not using such drugs (OR for any malformation 0.95; 95% CI 0.80, 1.12).

CONCLUSIONS

Our data suggest that the risk of adverse effects on pregnancy outcome associated with the use of drugs for migraine is low but data for triptans other than sumatriptan are still few.

Migraine and preterm birth

OBJECTIVE

To investigate whether maternal migraine was associated with preterm birth.

STUDY DESIGN

Case-control sample within a population-based study of risk factors for cerebral palsy (CP). Infants without CP were matched for gestational age with those with CP. Maternal migraine was self-identified at first prenatal visit, most in the first trimester.

RESULT

Infants without CP born to women with migraine had a higher rate of preterm birth (odds ratio (OR)=3.5, 95% confidence interval (CI) 1.5, 8.5), as did infants who died in the perinatal period (OR=7.3, 95% CI 0.98, 54), the difference marginal for nominal statistical significance. In all outcome groups, infants of women with migraine had a higher observed rate of suboptimal intrauterine growth. In term infants, the rate of maternal migraine was higher in those with CP than in controls (OR=2.18, 95% CI 0.92, 5.25). Pre-eclampsia was reported more frequently in women with migraine who gave birth to a child with CP or a perinatal death, particularly in those born preterm; OR=5.1 (1.3, 20) and OR=2.9 (1.1, 7.6), respectively, but not in women giving birth to a control whether term or preterm.

CONCLUSION

Maternal migraine, as self-reported early in pregnancy, was associated with preterm birth in survivors without CP and in infants who died in the perinatal period. The combination of maternal migraine and pre-eclampsia was associated with CP and perinatal death. The association of maternal migraine with outcomes of pregnancy warrants further study.

Migraine therapy during pregnancy and lactation

IMPORTANCE OF THE FIELD

Migraine affects about 25% of women during childbearing years but few data are available about the risks connected with most antimigraine drugs during pregnancy.

AREAS COVERED IN THIS REVIEW

In this report, we review the available data, mainly obtained from published studies, toxicology databases and clinical guidelines, on migraine treatment during pregnancy and lactation.

WHAT THE READER WILL GAIN

The following drugs should be preferred for the treatment of acute migraine attacks in pregnant women: paracetamol, NSAIDs and sumatriptan. Migraine prophylaxis should be undertaken when patients experience at least three prolonged severe attacks a month that are particularly incapacitating or unresponsive to symptomatic therapy and likely to result in complications. Non-pharmacologic approaches should be preferred, but if they are not effective, preventive treatment should include low doses of β-blockers and amitriptyline.

TAKE HOME MESSAGE

Migraine treatment is often necessary because maternal and fetal risks related to acute attacks may be more harmful than the therapy itself, especially if they are frequent, severe and associated with nausea, anorexia, vomiting, hypotension or dehydration. If non-pharmacologic treatments do not alleviate migraine symptoms, only few drugs can be used during pregnancy and lactation.

The risks of women with migraine during pregnancy

Most epidemiological studies demonstrate that women suffering from migraine note a significant improvement in their headaches during pregnancy. Both headache specialists and gynecologists commonly hold that migraine does not involve any risks to either the mother, or the fetus. Despite this, recent studies into the medical complications of pregnancy in migrainous women have cast doubts on this assumption. Indeed, most of these studies have revealed a significant association between migraine and hypertension in pregnancy (i.e. preeclampsia and gestational hypertension). Migraine has also been recently postulated as one of the major risk factors for stroke during pregnancy and the puerperium. Therefore, there is an urgent need for prospective studies on large numbers of pregnant women to determine the real existence and extent of the risks posed by migraine during pregnancy. In the meantime, while awaiting verification of this hypothesis, a pregnant woman with migraine must be subject to a particularly attentive screening by both the obstetrician and the headache specialist.

Triptan exposure during pregnancy and the risk of major congenital malformations and adverse pregnancy outcomes: results from the Norwegian Mother and Child Cohort Study

OBJECTIVE

To evaluate the safety of triptan therapy during pregnancy.

BACKGROUND

Information on the safety of triptan therapy during pregnancy is scarce and only available for sumatriptan, naratriptan, and rizatriptan. No associations with congenital malformations have been detected so far, but one study found a significant association between sumatriptan exposure during pregnancy and prematurity.

METHODS

The study population consisted of 69,929 pregnant women and their newborn children for whom data on drug exposure and pregnancy outcome were available. Information on triptan therapy and potential socio-demographic and medical confounding factors was obtained from the Norwegian Mother and Child Cohort Study. Information on congenital malformations and other adverse pregnancy outcomes was obtained from the Norwegian Medical Birth Registry. The datasets were linked via the women's personal identification number. Pearson's chi(2) tests and logistic regression analyses were used to identify associations between triptan therapy and pregnancy outcome.

RESULTS

No significant associations between triptan therapy during the first trimester and major congenital malformations (unadjusted OR: 1.0; 95% CI 0.8-1.3, adjusted OR: 1.0; 95% CI 0.7-1.2) or other adverse pregnancy outcomes were found. Triptan therapy during the second and/or third trimesters was significantly associated with atonic uterus (unadjusted OR: 1.5; 95% CI 1.1-1.9, adjusted OR: 1.4; 95% CI 1.1-1.8), and blood loss >500 mL during labor (unadjusted OR: 1.3; 95% CI 1.1-1.5, adjusted OR: 1.3; 95% CI 1.1-1.5).

CONCLUSIONS

Triptan therapy during pregnancy was not associated with an overall increased risk of congenital malformations. It cannot, however, be excluded that a difference in the risk between triptan use and individual or rare congenital malformations may exist. A slight increase in the risk of atonic uterus and hemorrhage was associated with triptan use during the second and/or third trimesters. Although the present findings are reassuring, confirmation in independent studies is warranted.

Increased risk of adverse pregnancy outcomes for women with migraines: a nationwide population-based study

Using a 3-year nationwide population-based database, this study aims to examine the risk of adverse pregnancy outcomes in women with migraines, including low birthweight (LBW), preterm birth, infants born small for gestational age, Caesarean section (CS) and pre-eclampsia. We identified a total of 4911 women with migraines who gave birth from 2001 to 2003, together with 24,555 matched women as a comparison cohort. Multivariate logistic regression analyses showed that after adjusting for potential confounders, the odds ratios were 1.16 [95% confidence intervals (CI) = 1.03-1.31, P = 0.014] for LBW, 1.24 (95% CI = 1.13-1.39, P < 0.001) for preterm births, 1.16 (95% CI = 1.07-1.24, P < 0.001) for CS and 1.34 (95% CI = 1.02-1.77, P = 0.027) for pre-eclampsia for women with migraines compared with unaffected mothers. We conclude that women with migraines were at increased risk of having LBW, preterm babies, pre-eclampsia and delivery by CS, compared with unaffected mothers.

Migraines during pregnancy linked to stroke and vascular diseases: US population based case-control study

OBJECTIVE

To examine the association between migraine and cardiovascular diseases during pregnancy. Design US population based case-control study.

SETTING

Nationwide inpatient sample, from the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality. Population 18,345,538 pregnancy related discharges from 2000 to 2003.

MAIN OUTCOME MEASURES

Diagnosis of migraine, as identified by ICD-9 codes 346.0 and 346.1. Stroke and other vascular diseases were identified by using standard ICD-9 codes.

RESULTS

From the hospital discharges with a pregnancy discharge code, 33 956 migraine codes were identified: 185 per 100 000 deliveries. Diagnoses that were jointly associated with migraine codes during pregnancy (excluding pre-eclampsia) were stroke (odds ratio 15.05, 95% confidence interval 8.26 to 27.4), myocardial infarction/heart disease (2.11, 1.76 to 2.54), pulmonary embolus/venous thromboembolism (3.23, 2.06 to 7.07), and hypertension (8.61, 6.43 to 11.54), as well as pre-eclampsia/gestational hypertension (2.29, 2.13 to 2.46), smoking (2.85, 2.53 to 3.21), and diabetes (1.96, 1.64 to 2.35). However, migraine was not associated with several non-vascular diagnoses (pneumonia, transfusions, postpartum infection or haemorrhage).

CONCLUSIONS

In this large, population based sample of pregnant women admitted to hospital, a strong relation existed between active peripartum migraine and vascular diagnoses during pregnancy. Because these data do not allow determination of which came first, migraine or the vascular condition, prospective studies of pregnant women are needed to explore this association further.

Headache and pregnancy

BACKGROUND

Many women who suffer from migraine and tension-type headaches (TTHs) have an improvement in the frequency of these headaches during pregnancy. At the same time pregnancy predisposes women to a number of potentially life-threatening conditions which can present with headache. Accurate diagnosis and treatment of headache during pregnancy is essential.

REVIEW SUMMARY

The primary objectives of this review are to: (1) Summarize the natural history of primary headache disorders, including migraine, tension-type, and cluster headaches during pregnancy, as well as the impact of migraine on pregnancy outcomes and complications.(2) Summarize the therapeutic options and strategies for managing headaches in pregnancy and (3) Discuss the causes of secondary headaches and the diagnostic evaluation for new onset headache during pregnancy.

CONCLUSION

Primary headache disorders, in particular TTHs and migraines, generally improve during pregnancy. However the frequency of improvement varies greatly. Because the pathophysiology of both migraines and TTHs is poorly understood, this limits our ability to predict improvement. Future research should be focused on headache pathophysiology and the effect of ovarian hormones and the pregnant state on headache pathogenesis.

Managing headache during pregnancy and lactation

Headache patterns for both primary and secondary headaches are often modified in women during pregnancy. Although approximately two thirds of women with migraines experience headache improvement during pregnancy; women who continue to suffer from migraine or other headaches during pregnancy need effective clinical care to include appropriate diagnostic studies, counseling about expectations during pregnancy and lactation, and modifications in therapeutic regimens to minimize risk to the fetus and nursing baby. This review describes the epidemiology of headache during pregnancy and lactation, to include both effects of these conditions on headache activity and possible concerns about how a maternal headache diagnosis may influence the course and outcome of pregnancy. Although restrictions in diagnostic testing and medication interventions are often necessary during pregnancy and breastfeeding, this review describes evaluation and management strategies that provide effective clinical care while minimizing risk to the developing baby.