Headache and pregnancy

Continuous combined oral contraceptive use versus vitamin E in the treatment of menstrual migraine: rationale and protocol of a randomized controlled trial (WHAT!)

BACKGROUND

Currently, there is no evidence-based hormonal treatment for migraine in women. Several small studies suggest a beneficial effect of combined oral contraceptives, but no large randomized controlled trial has been performed. As proof of efficacy is lacking and usage may be accompanied by potentially severe side effects, there is a great need for clarity on this topic.

METHODS

Women with menstrual migraine (n = 180) are randomly assigned (1:1) to ethinylestradiol/levonorgestrel 30/150 μg or vitamin E 400 IU. Participants start with a baseline period of 4 weeks, which is followed by a 12-week treatment period. During the study period, a E-headache diary will be used, which is time-locked and includes an automated algorithm differentiating headache and migraine days.

RESULTS

The primary outcome will be change in monthly migraine days (MMD) from baseline (weeks - 4 to 0) to the last 4 weeks of treatment (weeks 9 to 12). Secondary outcomes will be change in monthly headache days (MHD) and 50% responder rates of MMD and MHD.

CONCLUSIONS

The WHAT! trial aims to investigate effectivity and safety of continuous combined oral contraceptive treatment for menstrual migraine. Immediate implementation of results in clinical practice is possible.

TRIAL REGISTRATION

Clinical trials.gov NCT04007874 . Registered 28 June 2019.

Prevalence and course of pregnancy symptoms using self-reported pregnancy app symptom tracker data

During pregnancy, almost all women experience pregnancy-related symptoms. The relationship between symptoms and their association with pregnancy outcomes is not well understood. Many pregnancy apps allow pregnant women to track their symptoms. To date, the resulting data are primarily used from a commercial rather than a scientific perspective. In this work, we aim to examine symptom occurrence, course, and their correlation throughout pregnancy. Self-reported app data of a pregnancy symptom tracker is used. In this context, we present methods to handle noisy real-world app data from commercial applications to understand the trajectory of user and patient-reported data. We report real-world evidence from patient-reported outcomes that exceeds previous works: 1,549,186 tracked symptoms from 183,732 users of a smartphone pregnancy app symptom tracker are analyzed. The majority of users track symptoms on a single day. These data are generalizable to those users who use the tracker for at least 5 months. Week-by-week symptom report data are presented for each symptom. There are few or conflicting reports in the literature on the course of diarrhea, fatigue, headache, heartburn, and sleep problems. A peak in fatigue in the first trimester, a peak in headache reports around gestation week 15, and a steady increase in the reports of sleeping difficulty throughout pregnancy are found. Our work highlights the potential of secondary use of industry data. It reveals and clarifies several previously unknown or disputed symptom trajectories and relationships. Collaboration between academia and industry can help generate new scientific knowledge.

Headaches in Pregnancy and Postpartum: ACOG Clinical Practice Guideline No. 3

PURPOSE

To provide updated evidence-based recommendations for the evaluation and treatment of primary and secondary headaches in pregnancy and postpartum.

TARGET POPULATION

Pregnant and postpartum patients with a history of or experiencing primary or new secondary headaches.

METHODS

This guideline was developed using an a priori protocol in conjunction with a writing team consisting of two specialists in obstetrics and gynecology appointed by the ACOG Committee on Clinical Practice Guidelines-Obstetrics and one external subject matter expert. ACOG medical librarians completed a comprehensive literature search for primary literature within Cochrane Library, Cochrane Collaboration Registry of Controlled Trials, EMBASE, PubMed, and MEDLINE. Studies that moved forward to the full-text screening stage were assessed by two authors from the writing team based on standardized inclusion and exclusion criteria. Included studies underwent quality assessment, and a modified GRADE (Grading of Recommendations Assessment, Development, and Evaluation) evidence-to-decision framework was applied to interpret and translate the evidence into recommendation statements.

RECOMMENDATIONS

This Clinical Practice Guideline includes recommendations on interventions to prevent primary headache in individuals who are pregnant or attempting to become pregnant, postpartum, or breastfeeding; evaluation for symptomatic patients presenting with primary and secondary headaches during pregnancy; and treatment options for primary and secondary headaches during pregnancy and lactation. Recommendations are classified by strength and evidence quality. Ungraded Good Practice Points are included to provide guidance when a formal recommendation could not be made because of inadequate or nonexistent evidence.

Perinatal outcomes in women affected by different types of headache disorders: A prospective cohort study

OBJECTIVE

This study aims to investigate pregnancy and perinatal outcomes in women with tension-type headache, migraine without aura and migraine with aura by comparing them to women without any headache disorders.

STUDY DESIGN

Prospective cohort study including singleton pregnancies attending the first trimester aneuploidy screening at the University Hospital of Modena, in Northern Italy, between June 2018 and December 2019.

RESULTS

A total of 515 consecutive women were included and headache disorders were reported in 43.5% of them (224/515). Tension-type headache was diagnosed in 24.3% of the cases, while 14% suffered from migraine without aura and 5.2% from migraine with aura. Birthweight was significantly lower in women affected by migraine with aura respective to other groups, and a significantly higher rate of small for gestational age infants was found in tension-type headache (10.4%) and in migraine with aura (24.9%) groups respective to the others (p < 0.001). Moreover, the admission to the neonatal intensive care unit was significantly higher in all the headache groups (p = 0.012). Multivariate analysis showed that women presenting tension-type headache (OR 4.19, p = 0.004), migraine with aura (OR 5.37, p = 0.02), a uterine artery pulsatility index >90th centile (OR 3.66, p = 0.01), low multiple of the median (MoM) of Pregnancy-associated plasma protein-A (PAPP-A) (OR 0.48, p = 0.05) and high MoM of Inhibin-A (OR 3.24, p = 0.03) at first trimester, are independently associated with the delivery of small for gestational age infants when compared to women without headache disorders.

CONCLUSION

Migraine with aura and tension type headache expose women to an increased risk of delivering small for gestational age infants, in association with some utero-placenta markers evaluated at first trimester. These women with headache disorders have an additional indication to undergo first trimester aneuploidy screening and would possibly benefit from specific interventions.

Effect of Migraine on Pregnancy Planning: Insights From the American Registry for Migraine Research

OBJECTIVE

To evaluate the effect of migraine on women's pregnancy plans.

PATIENTS AND METHODS

Participants were enrolled in the American Registry for Migraine Research, an observational study that recruits patients from headache specialty clinics across the United States. Data for this analysis were collected via patient-completed questionnaires completed from February 1, 2016, through September 23, 2019. Participants were adult women with migraine who answered the American Registry for Migraine Research family planning questions.

RESULTS

Of 607 women, 19.9% (n=121) avoided pregnancy because of migraine. Compared with women who did not avoid pregnancy, those who did were younger (37.5±9.2 years vs 47.2±13.3 years; P<.001), had fewer children (0.8±1.1 vs 1.5±1.5; P<.001), and were more likely to have chronic migraine (n=99 [81.8%] vs n=341 [70.2%]; P=.012) and menstrually associated migraine (n=5 [4.1%] vs n=5[1.0%]; P=.031). Women who avoided pregnancy believed that their migraine would be worse during pregnancy (n=87[72.5%]), disability caused by migraine would make pregnancy difficult (n=82[68.3%]), the migraine medications they take would negatively affect their child's development (n=92[76.0%]), and migraine would cause the baby to have abnormalities at birth (n=17[14.0%]).

CONCLUSION

Migraine effects pregnancy plans of many women, especially of those who are younger and have menstrual migraine and chronic migraine. Women who avoid pregnancy because of migraine believe that migraine will worsen during pregnancy, make their pregnancy difficult, and have negative effects on their child. Study results highlight the importance of educating women with migraine about the relationships between migraine and pregnancy so that informed family planning decisions can be made.

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.

Sleep disturbances among pregnant women with history of migraines: A cross-sectional study

BACKGROUND

Migraine is associated with sleep disturbances in men and non-pregnant women. However, relatively little is known about sleep disturbances among pregnant migraineurs. We investigated sleep disturbances among pregnant women with and without history of migraine.

METHODS

This cross-sectional study was conducted among 1324 women who were recruited during early pregnancy. Migraine diagnoses were based on the International Classification of Headache Disorders-II criteria. The Pittsburgh Sleep Quality Index (PSQI) questionnaire was used to evaluate sleep-related characteristics including sleep duration, sleep quality, excessive daytime sleepiness, and other sleep traits. Multivariable logistic regression procedures were used to estimate adjusted odds ratios (AORs) and 95% confidence intervals (CIs).

RESULTS

Migraineurs were more likely than non-migraineurs to report short sleep duration (<6.5 hours) (AOR = 1.47, 95% CI 1.07-2.02), poor sleep quality (PSQI>5) (AOR = 1.73, 95% CI 1.35-2.23), and daytime dysfunction due to sleepiness (AOR = 1.51, 95% CI 1.12-2.02). Migraineurs were also more likely than non-migraineurs to report taking sleep medication during pregnancy (AOR = 1.71, 95% CI 1.20-2.42). Associations were generally similar for migraine with or without aura. The odds of sleep disturbances were particularly elevated among pre-pregnancy overweight migraineurs.

CONCLUSION

Migraine headache and sleep disturbances are common comorbid conditions among pregnant women.

[Current approaches to treatment of migraine during pregnancy]

Migraine is one of the most common complaints in the majority of pregnant women. Migraine without aura is the most frequent cause of headache. Improvement of this disease is reported in 50-80% of patient. However, about one third of pregnant women have severe prolonged attacks with marked concomitant symptoms and maladaptation that necessarily need treatment. Authors consider the issues of differential diagnosis and principles of management of these patients.

Migraine in pregnancy and lactation

Migraine headache is a significant health problem affecting women more than men. In women, the hormonal fluctuations seen during pregnancy and lactation can affect migraine frequency and magnitude. Understanding the evaluation of headache in pregnancy is important, especially given the increased risk of secondary headache conditions. Pregnancy and lactation can complicate treatment options for women with migraine because of the risk of certain medications to the fetus. This review includes details of the workup and then provides treatment options for migraine during pregnancy and lactation.

Headache and neurological disease in pregnancy

A review of the approach in pregnancy to a very commonly encountered neurological disorder (headache), along with less commonly encountered neurological entities that none the less deserve the obstetrician's attention. Definitions of specific disorders and differential diagnoses are reviewed, along with treatment options and pregnancy-associated morbidities. Headache is reviewed first including the common primary headaches migraine and tension-type headache. The disabling neurological disorders-multiple sclerosis, cerebral palsy, and spinal cord injury are grouped due to common morbidities affecting pregnancy. Finally, Bell palsy is also reviewed.

Impact of sex hormonal changes on tension-type headache and migraine: a cross-sectional population-based survey in 2,600 women

Sex hormones have some implications on headaches. The objective of the study was to investigate the effects of hormonal changes comparatively on tension-type headache (TTH) and migraine, in a population-based sample. A nationwide face-to-face prevalence study was conducted using a structured electronic questionnaire. 54.3 % of the migraineurs reported that the probability of experiencing headache during menstruation was high, whereas 3.9 % had headache only during menstruation. Forward logistic regression analysis revealed that menstruation was a significant trigger for migraine in comparison to TTH. On the other hand, nearly double the number of TTH sufferers reported “pure menstrual headache” compared to migraineurs (p = 0.02). Menstrual headaches caused significantly higher MIDAS grades. One-third of the definite migraineurs reported improvement during pregnancy and oral contraceptives significantly worsened migraine. Menopause had a slight improving effect on migraine compared to TTH. Sex hormonal changes have major impacts particularly on migraine; however, the effects of hormonal fluctuations on TTH should not be underestimated.

Utilization of topiramate during pregnancy and risk of birth defects

OBJECTIVE

To evaluate the risk of oral cleft and major congenital malformation occurrence in infants born to women exposed to topiramate in their first trimester of pregnancy compared with women who used other anti-epileptic drugs or those with disease states in which topiramate may have been used.

METHODS

Sourced from patients' pharmacy and medical claims from 2002 through 2010, this study identified infants born from mothers exposed to topiramate (n = 870) and other anti-epileptic drugs (n = 3615) in the first trimester of pregnancy. First trimester exposure was based on prescription dispensing dates and days supplied relative to infant birth date, accounting for premature delivery. Infants born to women with migraine without epilepsy (n = 26,865), women with epilepsy (n = 2607), and women with diabetes mellitus (n = 13,062), as well as randomly sampled women (n = 99,761), were used for comparison. Topiramate use was excluded from all groups with the exception of the topiramate and random sample cohorts. Non-anti-epileptic drug teratogens were excluded from each cohort (except random sample). Unadjusted relative risks and 95% confidence intervals for topiramate vs each comparator were calculated. Risks >1 indicate a higher risk with topiramate vs comparator, whereas risks <1 indicate a lower risk with topiramate vs comparator.

RESULTS

The frequency of oral clefts was 0.23% for topiramate use, 0.17% for other anti-epileptic drug use (topiramate vs comparator relative risk = 1.39 [95% confidence interval: 0.28-6.85]), 0.16% for migraineurs (1.47 [0.36-6.06]), 0.31% for epileptics (0.75 [0.16-3.52]), 0.26% for diabetics (0.88 [0.21-3.67]), and 0.16% for the random sample (1.44 [0.36-5.81]). The frequency of major congenital malformations was 4.33% for topiramate use, 3.21% for other anti-epileptic drugs (1.33 [0.92-1.90]), 3.79% for migraineurs (1.12 [0.81-1.55]), 4.33% for epileptics (0.98 [0.68-1.41]), 6.58% for diabetics (0.65 [0.47-0.89]), and 3.77% for the random sample (1.13 [0.82-1.55]).

CONCLUSIONS

This retrospective study quantified the association between topiramate exposure during pregnancy and the risk of oral cleft or major congenital malformations, and suggested little or no increase in risk in comparison with exposure to other anti-epileptic drugs or to disease states, such as migraine, epilepsy, or diabetes. However, small numbers of events limit the strength of inferences.

Prevalence of and influencing factors for chronic headaches among pregnant women

OBJECTIVE

To determine the prevalence of headaches and their influencing factors among pregnant women.

METHODS

A cross-sectional study was conducted from January 3 to April 29, 2005, with 1357 women receiving routine pregnancy check-ups at the obstetric clinics of the community health institutions of Kayseri, Turkey. A structured questionnaire and the Zung Depression Scale were used to collect data.

RESULTS

Overall, 24.6% (95% confidence interval, 22.3%-26.9%) of the participants had headaches before pregnancy, whereas only 17.9% (95% confidence interval, 15.9%-20.1%) had headaches during pregnancy. Although the headache prevalence was lower during than before pregnancy, it was high among the participants aged 35 years or older, those who received help in their housework, and those who were multiparous. Moreover, the Zung depression score was significantly high among those experiencing headaches.

CONCLUSION

The significant decrease in headache prevalence observed during pregnancy may be the result of a pregnancy-specific hormonal status. However, the most significant factors influencing the frequency of headaches in the participants were related to their socioeconomic status and the severity of depression.

Headache in pregnancy: a nuisance or a new sense?

Headache is a very commonly encountered symptom in pregnancy and is usually due to primary headache disorders which are benign in nature. It can however be quite debilitating for some women who may need therapeutic treatment of which there are several options safe to use in pregnancy. It is equally important though to recognise that headache may be a sign of serious underlying pathology. This paper aims to provide a clinically useful guidance for differentiation between primary and secondary headaches in pregnancy. The primary headache disorders and their management in pregnancy are explored in depth with brief overviews of the causes for secondary headaches and their further investigation and management.

Trimester-specific blood pressure levels and hypertensive disorders among pregnant migraineurs

OBJECTIVE

We evaluated the influence of physician-diagnosed migraine on blood pressure levels and the risk of hypertensive disorders of pregnancy in a clinic-based prospective cohort study of 3373 healthy pregnant women.

BACKGROUND

The relationship between migraine and blood pressure is controversial with results from several studies suggesting positive associations, while others suggest null or inverse associations. To our knowledge, no previous study has investigated blood pressure profiles among pregnant migraineurs.

METHODS

We abstracted blood pressure values and delivery information from medical records of women presenting to prenatal clinics in Washington State. Mean blood pressure differences for pregnant migraineurs and non-migraineurs were estimated in regression models, using generalized estimating equations. We calculated odds ratios and 95% confidence intervals (95% CIs) for gestational hypertension and preeclampsia in relation to migraine status.

RESULTS

Mean first, second, and third trimester systolic blood pressures (SBP) were elevated among pregnant migraineurs as compared with non-migraineurs. Migraineurs had higher mean third trimester SBP (4.08 mmHg) than non-migraineurs. Trimester-specific diastolic blood pressure (DBP) values were variably related with migraine status. Mean first (0.82 mmHg) and third (2.39 mmHg) trimester DBP were higher, and second trimester DBP values were lower (-0.24) among migraineurs as compared with non-migraineurs. Migraineurs had a 1.53-fold increased odds of preeclampsia (95% CI 1.09 to 2.16). Additionally, migraineurs who were overweight or obese had a 6.10-fold increased odds of preeclampsia (95% CI 3.83 to 9.75) as compared with lean non-migraineurs.

CONCLUSIONS

Pregnant migraineurs had elevated blood pressures, particularly SBP measured in the third trimester, and a higher risk of preeclampsia than pregnant women without migraine. Observed associations were more pronounced among overweight or obese migraineurs. Our findings add to the accumulating evidence of adverse pregnancy outcomes among migraineurs.

Risk of preterm delivery and hypertensive disorders of pregnancy in relation to maternal co-morbid mood and migraine disorders during pregnancy

We evaluated the risks of preterm delivery and hypertensive disorders of pregnancy among pregnant women with mood and migraine disorders, using a cohort study of 3432 pregnant women. Maternal pre-pregnancy or early pregnancy (<20 weeks gestation) mood disorder and pre-pregnancy migraine diagnoses were ascertained from interview and medical record review. We fitted generalised linear models to derive risk ratios (RR) and 95% confidence intervals (CI) of preterm delivery and hypertensive disorders of pregnancy for women with isolated mood, isolated migraine and co-morbid mood-migraine disorders, respectively. Reported RR were adjusted for maternal age, race/ethnicity, marital status, parity, smoking status, chronic hypertension or pre-existing diabetes mellitus, and pre-pregnancy body mass index. Women without mood or migraine disorders were defined as the reference group. The risks for preterm delivery and hypertensive disorders of pregnancy were more consistently elevated among women with co-morbid mood-migraine disorders than among women with isolated mood or migraine disorder. Women with co-morbid disorders were almost twice as likely to deliver preterm (adjusted RR=1.87, 95% CI 1.05, 3.34) compared with the reference group. There was no clear evidence of increased risks of preterm delivery and its subtypes with isolated migraine disorder. Women with mood disorder had elevated risks of pre-eclampsia (adjusted RR=3.57, 95% CI 1.83, 6.99). Our results suggest an association between isolated migraine disorder and pregnancy-induced hypertension (adjusted RR=1.42, 95% CI 1.00, 2.01). This is the first study examining perinatal outcomes in women with co-morbid mood-migraine disorders. Pregnant women with a history of migraine may benefit from screening for depression during prenatal care and vigilant monitoring, especially for women with co-morbid mood and migraine disorders.

Body mass index and adult weight gain among reproductive age women with migraine

OBJECTIVE

To evaluate the cross-sectional relationship between migraine and pregravid obesity; and to assess the risk of adult weight gain among women with history of a pediatric diagnosis of migraine.

BACKGROUND

Obesity, comorbid with pain disorders including migraine, shares common pathophysiological characteristics including systemic inflammation, and derangements in adipose-tissue derived cytokines. Despite biochemical and epidemiological commonalities, obesity-migraine associations have been inconsistently observed.

METHODS

A cohort of 3733 women was interviewed during early pregnancy. We ascertained participants' self-reported history of physician-diagnosed migraine and collected self-reported information about pregravid weight, adult height, and net weight change from age 18 to the 3-months period before pregnancy. Using pregravid body mass index, we categorized participants as follows: lean (< 18.5 kg/m²), normal (18.5-24.9 kg/m²), overweight (25-29.9 kg/m²), obese (30-34.9 kg/m²), severely obese (35-39.9 kg/m²), and morbidly obese (≥ 40 kg/m²). Logistic regression procedures were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

After adjusting for confounders, relative to normal weight women, obese women had a 1.48-fold increased odds of migraine (OR = 1.48; 95% CI 1.12-1.96). Severely obese (OR = 2.07; 95% CI 1.27-3.39) and morbidly obese (OR = 2.75; 95% CI 1.60-4.70) had the highest odds of migraines. Women with a history of diagnosed pediatric migraine had a 1.67-fold higher odds of gaining ≥ 10.0 kg above their weight at age 18, as compared with non-migraineurs (OR = 1.67; 95% CI 1.13-2.47).

CONCLUSION

These data support earlier observations of migraine-obesity association among women, and extend the literature to include evidence of adult weight gain among women with a history of pediatric migraine.

Association between intimate partner violence, migraine and probable migraine

OBJECTIVE

Intimate partner violence (IPV) among women is a global public health problem. The association between childhood maltreatment and migraine is well established, but not the association between IPV and migraine. The aim of this cross-sectional study was to evaluate the relationship between type and severity of IPV and migraine in a large cohort of Peruvian women.

METHODS

Women who delivered singleton infants (n = 2066) at the Instituto Nacional Materno Perinatal, Lima, Peru were interviewed during their postpartum hospital stay. Participants were queried about their lifetime experiences with headaches and migraine, and with physical and sexual violence. The International Classification of Headache Disorders (ICHD-2) diagnostic criteria were used to classify participants according to their migraine status. Questions on physical and sexual violence were adapted from the protocol of Demographic Health Survey Questionnaires and Modules: Domestic Violence Module and the World Health Organization (WHO) Multi-Country Study on Violence against Women. Depressive symptoms were assessed using a modified version of the Patient Health Questionnaire-9. Logistic regression was used to estimate multivariate adjusted odds ratios (aOR) and 95% confidence intervals (CI).

RESULTS

Compared with women without a history of violence, women with experiences of lifetime physical or sexual violence (aOR = 1.44, 95% CI 1.19-1.75), physical violence only (aOR = 1.36, 95% CI 1.10-1.68), sexual violence only (aOR = 1.76, 95% CI 0.97-3.21), and both physical and sexual violence (aOR = 1.61, 95% CI 1.12-2.31) had increased odds of any migraine after adjusting for maternal age, parity, and access to basic foods. There was no gradient of increased odds of any migraine with severity of physical violence. The relationship between IPV and any migraine was strongest among women with moderate to severe levels of depressive symptoms. The odds of any migraine was increased 2.25-fold (95% CI 1.75-2.28) among abused women who also had moderate to severe levels of depressive symptomology compared with women who were not abused and had none or mild levels of depressive symptomology. Associations from sensitivity analyze that segregated women according to probable migraine (ICHD-2 category 1.6.1) and migraine (ICHD-2 category 1.1) diagnoses were of similar magnitudes as those reported here for women with any migraine diagnoses. IPV, particularly sexual violence, appears to be a risk factor for migraine.

CONCLUSION

Our findings suggest the potential importance of considering a history of violence among migraineurs.

Depressive symptoms and migraine comorbidity among pregnant Peruvian women

BACKGROUND

Migraine and depression are known to be comorbid conditions in non-pregnant women and men. However, the migraine-depression comorbidity among pregnant women, particularly women in developing countries has not been evaluated. Therefore, we evaluated the migraine-depressive symptom relationship in a large cohort of pregnant Peruvian women.

METHODS

Women who delivered singleton infants (n=2293) at the Instituto Nacional Materno Perinatal, Lima, Peru were interviewed during the postpartum hospital stay. Women were asked questions related to their lifetime and pregnancy experiences with headaches and migraines. Responses to these questions enabled the classification of "probable" and "strict" migraines according to the International Headache Society diagnostic criteria. Depressive symptoms were assessed using the nine-item Patient Health Questionnaire Depression Subset. Logistic regression procedures were used to estimate adjusted odds ratios (AORs) and 95% confidence intervals (CIs).

RESULTS

Approximately 32% of the women reported a history of migraine, while 41% reported experiencing moderate to severe depressive symptoms during pregnancy. Compared with women without a history of migraine, women with strict migraine had AORs of 2.12 (95% CI 1.54-2.93), 1.85 (95% CI 1.16-2.96) and 2.23 (95% CI 1.08-4.62) for moderate, moderately severe and severe depressive symptoms, respectively.

CONCLUSION

This is the first report of a cross-sectional association between migraine and depressive symptoms in pregnant women. If our findings are confirmed, pregnant women with a history of migraine may benefit from increased vigilance for screening and treating depressive symptoms.

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.

Maternal characteristics and migraine pharmacotherapy during pregnancy: cross-sectional analysis of data from a large cohort study

Little is known about factors associated with migraine pharmacotherapy during pregnancy. Of 60 435 pregnant women in a population-based cohort, 3480 (5.8%) reported having migraine during the first 5 months of pregnancy. Of these, 2525 (72.6%) reported using migraine pharmacotherapy, mostly non-narcotic analgesics (54.1%) and triptans (25.4%). After adjustment for sociodemographic factors and comorbidities in logistic regression analysis, high pregestational body mass index [odds ratio (OR) 1.3, 95% confidence interval (CI) 1.2, 1.4], sleep < 5 h (OR 1.6, 95% CI 1.3, 1.9), being on sick-leave (OR 1.3, 95% CI 1.2, 1.5) and acute back/shoulder/neck pain (OR 0.6, 95% CI 0.6, 0.7) were associated with migraine pharmacotherapy during pregnancy. Many women need drug treatment for migraine during pregnancy, and the choice of pharmacotherapy during this period may be influenced by maternal sociodemographic factors and comorbidities.