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

History of maternal migraine and its association with preeclampsia: A case-control study in a low-resource setting in Sudan, Africa

BACKGROUND

Previous studies have reported various levels of association between migraine and preeclampsia. However, there are no published data on migraine and its association with preeclampsia in African countries, including Sudan.

METHODS

A case-control study was conducted at Rabak Maternity Hospital in White Nile State, Central Sudan. The cases were pregnant women with preeclampsia, while the controls were healthy pregnant women. All participants were interviewed using questionnaire. The adjusted odds ratio (AOR) and a 95% confidence interval (CI) were calculated in a multivariate regression analysis.

RESULTS

Of 148 pregnant women with preeclampsia, 96 (64.9%) women had mild preeclampsia and 52 (35.1%) women had severe preeclampsia. Of the 148 study participants with preeclampsia, 57 (38.5%) had a history of migraine and 19/296 (6.4%) women in control group had a history of migraine (p < 0.001). Pregnant women with a history of migraine have higher odds of preeclampsia than pregnant women without a history of migraine (AOR = 9.01, 95% CI = 4.81-16.86). A history of preeclampsia, being overweight and obesity were associated with preeclampsia.

CONCLUSION

Our findings are consistent with the findings of previous studies on the association between migraine and preeclampsia. More studies are needed on this topic.

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.

Migraine and risk of hypertensive disorders of pregnancy: A population-based cohort study

BACKGROUND

Migraine is associated with hypertensive disorders of pregnancy through common pathophysiological features. This study evaluates the association between migraine diagnosis and treatment, and risk of hypertensive disorders of pregnancy.

METHODS

We conducted a prospective cohort study in the Clinical Practice Research Datalink GOLD, a large longitudinal database of patient records in the UK. We analyzed data from liveborn or stillborn singleton deliveries from 1993-2020 with at least 24 months of medical history and no history of cardiovascular disease (n = 1,049,839). We ascertained migraine through diagnosis or prescription codes before 20 weeks of gestation and hypertensive disorders of pregnancy through diagnosis codes between 20 weeks of pregnancy and delivery. We used log-binomial regression models to estimate the risk ratio and 95% confidence intervals, comparing risk of hypertensive disorders of pregnancy among individuals with migraine to those without migraine, adjusting for confounders.

CONCLUSIONS

A history of migraine prior to pregnancy was associated with an increased risk of hypertensive disorders of pregnancy (RR = 1.17, 95% CI: 1.09-1.26). The greatest risk was among those with pre-pregnancy migraine that persisted into the first trimester (RR = 1.84, 95% CI: 1.35-2.50). Use of migraine medication was associated with a higher risk of hypertensive disorders of pregnancy compared to non-migraineurs (RR = 1.50, 95% CI: 1.15-1.97). Results from this study indicate that migraine is a potential risk factor for hypertensive disorders of pregnancy.

Migraine treatment in pregnancy: A survey of comfort and treatment practices of women's healthcare providers

OBJECTIVE

The objective of this study was to assess women's healthcare providers' treatment practices for pregnant women with migraine.

BACKGROUND

Migraine is associated with several maternal and fetal complications during pregnancy, including preeclampsia and preterm birth. Migraine treatment during pregnancy can present significant challenges due to lack of controlled clinical trials and risks associated with specific medications.

METHODS

Women's healthcare providers were queried regarding practice patterns and comfort with use of acute and preventive migraine treatments during pregnancy. The survey was distributed online.

RESULTS

The survey was completed by 92 women's healthcare providers (response rate 22.9% [92/402]), with most specializing in general obstetrics and gynecology (91% [83/92]). Approximately one-fourth (26% [24/92]) of respondents indicated they counseled women on migraine treatment in pregnancy as early as before pregnancy contemplation, while over one-third (35% [32/92]) counseled on migraine treatment once the patient became pregnant. The majority of respondents reported feeling somewhat or very comfortable with recommending (63% [58/92]) or continuing (64% [59/92]) acute treatments for pregnant patients with migraine, with highest comfort levels for acetaminophen (100% [92/92] for prescribing or continuing) and caffeine (94% [85/90] prescribing, 91% [82/90] continuing). Higher levels of discomfort were reported with triptans (88% [80/91] rarely or never prescribe during pregnancy). Survey respondents felt less comfortable with recommending preventive migraine treatments to pregnant patients (40% [37/92] somewhat or very comfortable), compared with a higher comfort level with continuing preventive medications (63% [58/92] somewhat or very comfortable). Highest comfort levels were reported with use of magnesium (69% [63/91] comfortable prescribing, 82% [75/92] comfortable continuing) and non-pharmacologic approaches (70% [62/89] comfortable prescribing, 84% [75/89] comfortable continuing). Nearly 40% (35/92) of respondents reported that they typically refer to neurologists or headache specialists for migraine treatment during pregnancy.

CONCLUSION

This survey of women's healthcare providers revealed varying levels of comfort regarding migraine management during pregnancy, and highlights the need for additional education regarding migraine treatment safety data during pregnancy.

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.

Population-Based Study of Nonelective Postpartum Readmissions in Women With Stroke, Migraine, Multiple Sclerosis, and Myasthenia Gravis

OBJECTIVE

To compare maternal obstetric complications and nonelective readmissions in women with common neurologic comorbidities (WWN) vs women without neurologic disorders.

METHODS

We performed a retrospective cohort study of index characteristics and acute postpartum, nonelective rehospitalizations from the 2015-2017 National Readmissions Database using ICD-10 codes. Wald χ² testing compared baseline demographic, hospital, and clinical characteristics and postpartum complications between WWN (including previous stroke, migraine, multiple sclerosis [MS], and myasthenia gravis [MG]) and controls. Multivariable logistic regression models examined odds of postpartum complications and nonelective readmissions within 30 and 90 days for each neurologic comorbidity compared to controls (α = 0.05).

RESULTS

A total of 7,612 women with previous stroke, 83,430 women with migraine, 6,760 women with MS, 843 women with MG, and 8,136,335 controls met the criteria for index admission after viable infant delivery. WWN were more likely than controls to have inpatient diagnoses of edema, proteinuria, or hypertensive disorders and to have received maternal care for poor fetal growth. The adjusted odds of a Centers for Disease Control and Prevention severe maternal morbidity indicator were greater for women with previous stroke (adjusted odds ratio [AOR] 8.53, 95% CI 7.24-10.06), migraine (AOR 2.04, 95% CI 1.85-2.26), and MG (AOR 4.45, 95% CI 2.45-8.08) (all p < 0.0001). Readmission rates at 30 and 90 days for WWN were higher than for controls (30 days: previous stroke 2.9%, migraine 1.7%, MS 1.8%, MG 4.3%, controls 1.1%; 90 days: previous stroke 3.7%, migraine 2.5%, MS 5.1%, MG 6.0%, controls 1.6%). Women with MG had the highest adjusted odds of readmission (30 days: AOR 3.96, 95% CI 2.37-6.65, p < 0.0001; 90 days: AOR 3.30, 95% CI 1.88-5.78, p < 0.0001).

DISCUSSION

WWN may be at higher risk of severe maternal morbidity at the time of index delivery and postpartum readmission. More real-world evidence is needed to develop research infrastructure and create efficacious interventions to optimize maternal-fetal outcomes in WWN, especially for women with previous stroke or MG.

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.

Associations between adverse childhood experiences and migraine among teenage mothers in Peru

OBJECTIVE

The objective of this study was to evaluate the association between (1) different types of ACEs and migraine, and (2) the number of ACEs and migraine among adolescent mothers in Lima, Peru.

METHODS

Our cross-sectional study included 787 adolescent mothers (14- to 18-years of age) in Peru. In-person interviews were conducted postpartum, in hospital, within 2-days of delivery. Nine types of ACEs were assessed, including exposure to three categories of abuse, two categories of neglect, and four categories of household dysfunction. Multivariable logistic regression procedures were used to estimate odds ratios (ORs) and 95% confidence intervals (95% CI) for the association between ACEs and migraine while adjusting for putative confounders.

RESULTS

Approximately 75% of adolescent mothers reported having experienced at least one type of ACE. Adolescent mothers who reported any childhood abuse had 1.49-fold increased odds of migraine (aOR = 1.49; 95% CI 1.03-2.18) compared to those with no history of childhood abuse. Adolescent mothers who reported experiencing household dysfunction had 1.56-fold increase odds of migraine (aOR = 1.56; 95% CI 1.09-2.24). Compared to participants who reported no ACE, those who experienced four or more ACEs had 3.09-fold (aOR = 3.09; 95% CI 1.80-5.40) increased odds of migraine (ptrend < 0.001).

CONCLUSION

Exposure to ACEs is highly prevalent in adolescent-aged mothers postpartum and is associated with increased odds of migraine. These findings support the importance of screening for ACEs and migraine among adolescent mothers; and the need for providing culturally appropriate, trauma-informed headache care.

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.

Migraine in children and adults born preterm: A nationwide register linkage study

OBJECTIVE

Being born preterm is related to adverse health effects later in life. We studied whether preterm birth predicts the risk of migraine.

METHODS

In this nationwide register study, we linked data from six administrative registers for all 235,624 children live-born in Finland (January 1987 to September 1990) and recorded in the Finnish Medical Birth Register. n = 228,610 (97.0%) had adequate data and were included. Migraine served as primary outcome variable and was stringently defined as a diagnosis from specialised health care and/or ≥2 reimbursed purchases of triptans. We applied sex- and birth year-stratified Cox proportional hazard regression models to compute hazard ratios and confidence intervals (95% confidence intervals) for the association between preterm categories and migraine. The cohort was followed up until an average age of 25.1 years (range: 23.3-27.0).

RESULTS

Among individuals born extremely preterm (23-27 completed weeks of gestation), the adjusted hazard ratios for migraine was 0.55 (0.25-1.24) when compared with the full-term reference group (39-41 weeks). The corresponding adjusted hazard ratios and 95% confidence intervals for the other preterm categories were: Very preterm (28-31 weeks); 0.95 (0.68-1.31), moderately preterm (32-33 weeks); 0.96 (0.73-1.27), late preterm (34-36 weeks); 1.01 (0.91-1.11), early term (37-38 weeks); 0.98 (0.93-1.03), and post term (42 weeks); 0.98 (0.89-1.08). Migraine was predicted by parental migraine, lower socioeconomic position, maternal hypertensive disorder and maternal smoking during pregnancy.

CONCLUSION

We found no evidence for a higher risk of migraine among individuals born preterm.

The Potential Protective Role of Aspirin Against Migraine in Pregnant Women

Females are highly predisposed to the occurrence of migraine, a recurrent neurovascular headache disorder. Although migraine improves or disappears during pregnancy, a significant association between migraine and hypertension (i.e., pre-eclampsia) or vascular complications (i.e., stroke) during gestation has been determined. Low-dose aspirin exerts an antithrombotic effect and can improve vascular resistance by regulating endothelial function, which are implicated in the pathogenesis of migraine, pre-eclampsia, and other vascular complications during pregnancy. Low-dose aspirin is widely used prophylactically in the general population who are at higher risk of developing stroke or in pregnant women at higher risk of pre-eclampsia. In this paper we discuss the recent trends in research on the relationship between migraine and pre-eclampsia, an issue of paramount importance in obstetric care, and the potential relationship between migraine and vascular complications in pregnant women. In addition, the potential validity of low-dose aspirin prophylaxis in pregnant women with migraine is explored.

Evaluation of the Neurological Complaints during Pregnancy and Postpartum

BACKGROUND

Pregnancy and postpartum are critical periods for patients with neurological complications. In this study, we aimed to evaluate the clinical characteristics and outcome of pregnant women with neurological conditions.

MATERIALS AND METHODS

This cross-sectional study reviewed pregnant women with neurological signs and symptoms, who were registered in the Medical Care Monitoring Center (MCMC) database of Shiraz University of Medical Sciences 2013-15. A questionnaire was designed to record each patient's information including demographic variables, past medical history, clinical presentation, obstetric profile, and fetal/maternal outcomes.

RESULTS

Totally, 332 mothers were registered in the database. The main neurological complaints in our population were headache, seizure, unilateral neurological symptoms, multiple sclerosis, neuromuscular disorder, and brain tumor. More than half of the patients (54%) experienced headache during the pregnancy and postpartum period.

CONCLUSION

Evaluating the neurological disorders separately, based on the time of symptom onset indicates the importance of follow-up of mothers during peripartum. Our findings suggest that decisions for pregnancy in women with neurological disorders should be based on risks outweighing for the mother and the fetus, particularly regarding the pharmacological side effects.

Application of botulinum toxin in pregnancy and its impact on female reproductive health

Introduction: Botulinum toxin (BoNT) is a protein secreted by the anaerobic Gram-negative bacterium Clostridium botulinum. Among the seven known subtypes, type A is the most commonly used in women to treat diseases. It primarily blocks presynaptic release of acetylcholine at the neuromuscular junction, resulting in temporary muscle paralysis; thus, it is suitable for treating dystonia and other systemic diseases. BoNT is used widely for treating diseases that persist throughout, and may worsen during, pregnancy, such as cervical dystonia and achalasia. Thus, it is important to investigate whether BoNT injection during pregnancy causes side effects in pregnant women, fetuses, or newborns.Areas covered: This review highlights the efficiency and safety of BoNT injection in pregnancy. and assessed current literature with respect to the use of BoNT for disease treatment during pregnancy.Expert opinion: BoNT injection does not increase the risk of complications in pregnant women and fetuses. However, the use of BoNT to treat disease during pregnancy requires fully informed consent from patients. In addition, further research is needed to determine how to reduce the side effects of BoNT injection during pregnancy (e.g., by improving drug composition, or adjusting the amount of BoNT or the injection interval).

Migraine: navigating the hormonal minefield

Migraine affects 959 million people worldwide,1 with the highest prevalence being in women of childbearing age. The interplay between female hormones and migraine can be a challenging area to navigate since issues relating to pregnancy, contraception and the menopause are often out of the neurology comfort zone. This review aims to help the neurologist to manage women with migraine, from menarche to menopause.

Migraine during pregnancy and in the puerperium

Pregnancy can be seen as a positive time for women migraineurs because the elevated estrogen and endogenous opioid levels raise the pain threshold and the stable hormone levels, which no longer fluctuate, eliminate a major trigger factor for the attacks. In a great majority of cases, indeed, migraine symptoms spontaneously improve throughout pregnancy. Generally, migraine without aura (MO) improves better than migraine with aura (MA), which can occur ex novo in pregnancy more frequently than MO. After childbirth, the recurrence rate of migraine attacks increases, especially during the first month; breastfeeding exerts a protective effect against the reappearance of attacks. Migraine and pregnancy share a condition of hypercoagulability; therefore, attention must be paid to the risk of cardiovascular disorders, like venous thromboembolism and ischemic or hemorrhagic strokes. Some of these diseases can be linked to preeclampsia (PE), a serious complication of pregnancy, characterized by hypertension, proteinuria, or other findings of organ failure. This condition is more common in migraineurs compared with non-migraineurs; furthermore, women whose migraines worsen during pregnancy had a 13-fold higher risk of hypertensive disorders than those in which migraine remitted or improved. Pregnancy is generally recognized to exert a beneficial effect on migraine; nonetheless, clinicians should be on the alert for possible cardiovascular complications that appear to be more frequent in this patient population.

[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.

Serotonin-estrogen interactions: What can we learn from pregnancy?

We have reviewed the scientific literature related to four diseases in which to serotonin (5-HT) is involved in the etiology, herein named 5-HT-linked diseases, and whose prevalence is influenced by estrogenic status: depression, migraine, irritable bowel syndrome and eating disorders. These diseases all have in common a sex-dimorphic prevalence, with women more frequently affected than men. The co-occurrence between these 5-HT-linked diseases suggests that they have common physiopathological mechanisms. In most 5-HT-linked diseases (except for anorexia nervosa and irritable bowel syndrome), a decrease in the serotonergic tone is observed and estrogens are thought to contribute to the improvement of symptoms by stimulating the serotonergic system. Human pregnancy is characterized by a unique 5-HT and estrogen synthesis by the placenta. Pregnancy-specific disorders, such as hyperemesis gravidarum, gestational diabetes mellitus and pre-eclampsia, are associated with a hyperserotonergic state and decreased estrogen levels. Fetal programming of 5-HT-linked diseases is a complex phenomenon that involves notably fetal-sex differences, which suggest the implication of sex steroids. From a mechanistic point of view, we hypothesize that estrogens regulate the serotonergic system, resulting in a protective effect against 5-HT-linked diseases, but that, in turn, 5-HT affects estrogen synthesis in an attempt to retrieve homeostasis. These two processes (5-HT and estrogen biosynthesis) are crucial for successful pregnancy outcomes, and thus, a disruption of this 5-HT-estrogen relationship may explain pregnancy-specific pathologies or pregnancy complications associated with 5-HT-linked diseases.

Current concepts in migraine and their relevance to pregnancy

The prevalence of migraine in women of childbearing age is high, estimated at 24%. Migraine management during pregnancy and lactation can be challenging. Our understanding of the way in which medications affect the unborn fetus is still incomplete and the evidence is constantly changing with more recent emphasis on longitudinal studies and childhood development. The aim of this article is to describe the relationship between migraine and pregnancy and review the current evidence on treatment options in pregnancy and lactation.

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

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.

Managing Migraine During Pregnancy and Lactation

While over half of women with migraine report improvement during pregnancy, having a history of migraine may increase the chance of negative health outcomes. The state of pregnancy increases the risk of several dangerous secondary headache disorders, especially those associated with hypertensive disorders of pregnancy, and providers need to know the red flags to diagnose and treat emergently. Non-pharmacological migraine treatments can be instituted in advance of pregnancy as many are considered the safest options during pregnancy, but understanding the safety of medications and dietary supplements ensures appropriate care for the refractory migraine patient. New controversy exists over the safety of several historically routine and safe migraine treatment options in pregnancy, such as magnesium, acetaminophen, ondansetron, and butalbital. While it is not clear if breastfeeding decreases the postpartum recurrence of migraine, understanding safe treatment options during lactation can allow women to continue breastfeeding while achieving migraine relief.

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.

Depression, anxiety and stress among pregnant migraineurs in a pacific-northwest cohort

BACKGROUND

The co-occurrence of migraine and unipolar psychiatric disorders has been well documented in non-pregnant populations, however little is known in pregnant populations.

METHODS

A cohort of 1321 women was interviewed during the first trimester of pregnancy. At the time of interview lifetime migraine status was ascertained using International Classification of Headache Disorders diagnostic criteria (ICHD-II). Information regarding unipolar depression, anxiety and stress during pregnancy was collected using the Patient Health Questionnaire Depression Module-9 (PHQ-9), and the Depression Anxiety Stress Scales 21-item Short Form (DASS-21). Multivariable logistic regression procedures were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the association of migraine and mood disorders during pregnancy.

RESULTS

Approximately 28.2% (N=372) were classified as having a lifetime history of migraine; among migraineurs 122 were classified as migraineurs with aura and 250 as migraineurs without aura. Compared with non-migraineurs, migraineurs were associated with 1.60-fold increased odds of depression as measured by a PHQ-9 score ≥10 (AOR=1.60; 95% CI: 1.12-2.31). Overall, migraine with aura was more strongly associated with depression than was migraine without aura. Migraineurs, as compared with non-migraineurs, also had higher odds of mood disorders as measured by the DASS-21.

CONCLUSIONS

The comorbidity of mood and migraine disorders in pregnant populations supports the need for integrated mental and physical clinical evaluation, increased vigilance, and treatment of patients with such disorders.

Migraine, cardiovascular disease, and stroke during pregnancy: Systematic review of the literature

Objective

The objective of this article is to review the literature relating migraine, cardiovascular disease, and stroke during pregnancy in order to better define the relationship between migraines and vascular disease.

Methods

We conducted a systematic review of the literature using Medline and Cochrane Review with the following search terms: migraine AND pregnancy and vascular disease OR myocardial infarction OR heart disease OR stroke OR cerebrovascular disease OR hypertension in pregnancy. We also reviewed the bibliographies of papers identified in this search to obtain additional relevant studies.

Results

Of the 219 papers obtained with the primary search, we found 17 that were topically relevant. Altogether, there is an increased risk both of gestational hypertension (OR range from 1.23 to 1.68) and preeclampsia (OR range 1.08 to 3.5) in migraineurs compared to nonmigraineurs. In addition, there is an association between an increased risk of ischemic stroke in pregnancy (OR range 7.9 to 30.7), particularly with active migraine. There is also an association between migraine and increased risk of acute myocardial infarction and heart disease (OR 4.9; 95% CI 1.7, 14.2), and thromboembolic events during pregnancy (deep venous thrombosis OR 2.4; 95% CI 1.3, 4.2 and pulmonary embolus OR 3.1; 95% CI 1.7, 5.6).

Conclusion

In this review, we summarized the association between migraine and risk of vascular disease during pregnancy, based on the available literature. Given the limited amount of data, more research on these associations is needed to determine which women with migraine may be at risk while pregnant.

Antidepressant use and risk for preeclampsia

BACKGROUND

Prior studies suggest that women who use antidepressants during pregnancy have an increased risk for preeclampsia, yet the comparative safety of specific antidepressants remains unclear. US nationwide Medicaid Analytic eXtract (MAX) data have not been used to study medication safety during pregnancy.

METHODS

We identified 100,942 pregnant women with depression from 2000 to 2007 MAX data. We used pharmacy dispensing records to ascertain exposure to selective serotonin reuptake inhibitor (SSRI), serotonin-norepenephrine reuptake inhibitor (SNRI), tricyclic, bupropion, other antidepressant monotherapy or polytherapy, and specific antidepressants, during the second trimester and first half of the third trimester. Relative risks (RRs) and 95% confidence intervals (CIs) were adjusted for delivery year, preeclampsia risk factors, depression severity proxies, other antidepressant indications, other medications, and healthcare utilization.

RESULTS

The risk of preeclampsia was 5.4% among women with depression and no antidepressant exposure. Compared with these women, the risk for preeclampsia was higher among those receiving SNRI (RR: 1.52, 95% CI = 1.26-1.83) and tricyclic monotherapy (RR: 1.62, 95% CI = 1.23-2.12), but not SSRI monotherapy (RR: 1.00, 95% CI = 0.93-1.07) or other antidepressants. Compared with women receiving SSRI monotherapy, preeclampsia risk was higher among women with SNRI (RR: 1.54, 95% CI = 1.28-1.86) and tricyclic (RR: 1.64, 95% CI = 1.25-2.16) monotherapy. None of the specific SSRIs was associated with preeclampsia. The RR with venlafaxine was 1.57 (95% CI = 1.29-1.91) and with amitriptyline 1.72 (95% CI = 1.24-2.40).

CONCLUSIONS

In this population, SNRIs and tricyclics were associated with a higher risk of preeclampsia than SSRIs.

Triptan safety during pregnancy: a Norwegian population registry study

Knowledge on triptan safety during pregnancy remains limited to their class effect or studies on sumatriptan. Our aim was to evaluate the individual effect of four most frequently used triptans on several pregnancy outcomes. We used the Norwegian prescription database to access information on triptans redeemed by pregnant women living in Norway between 2004 and 2007. This database was linked to the Medical Birth Registry of Norway covering every institutional delivery in Norway and providing information on pregnancy, delivery, maternal and neonatal health. Estimates of associations with pregnancy outcomes were obtained by Generalised Estimation Equations analysis. Of the 181,125 women in our study, 1,465 (0.8%) redeemed triptans during pregnancy, and 1,095 (0.6%) redeemed triptans before pregnancy only (disease comparison group). The population comparison group comprised the remaining 178,565 women. Using this group as reference, we found no associations between triptan redemption during pregnancy and congenital malformations. Second trimester redemption was associated with postpartum haemorrhage (adjusted OR 1.57; 95% CI 1.19-2.07). The disease comparison group had an increased risk of major congenital malformations (adjusted OR 1.48; 95% CI 1.11-1.97), low birth weight (adjusted OR 1.39; 95% CI 1.08-1.81), and preterm birth (adjusted OR 1.30; 95% CI 1.06-1.60). The association of triptans with postpartum hemorrhage could be attributable to decreased platelet agreeability occurring in severe migraine. Likewise, the increased risk of major congenital malformations and other adverse pregnancy outcomes in the disease comparison group might be attributable to migraine severity.

Migraine in women: the role of hormones and their impact on vascular diseases

Migraine is a predominantly female disorder. Menarche, menstruation, pregnancy, and menopause, and also the use of hormonal contraceptives and hormone replacement treatment may influence migraine occurrence. Migraine usually starts after menarche, occurs more frequently in the days just before or during menstruation, and ameliorates during pregnancy and menopause. Those variations are mediated by fluctuation of estrogen levels through their influence on cellular excitability or cerebral vasculature. Moreover, administration of exogenous hormones may cause worsening of migraine as may expose migrainous women to an increased risk of vascular disease. In fact, migraine with aura represents a risk factor for stroke, cardiac disease, and vascular mortality. Studies have shown that administration of combined oral contraceptives to migraineurs may further increase the risk for ischemic stroke. Consequently, in women suffering from migraine with aura caution should be deserved when prescribing combined oral contraceptives.

Migraine and erectile dysfunction: Evidence from a population-based case-control study

Background: This case-control study aimed to estimate the association between erectile dysfunction (ED) and migraines using a nationwide population-based database in Taiwan.

Methods: The data used for this matched case-control study were retrieved from the Taiwan Longitudinal Health Insurance Database 2000. We identified 5763 patients with ED as the cases and randomly selected 17,289 patients as the controls. Conditional logistic regression was used to calculate the odds ratios (OR) for prior migraine between cases and controls.

Results: After adjusting for hypertension, diabetes, hyperlipidaemia, renal disease, coronary heart disease, obesity, and alcohol abuse/alcohol dependence syndrome, conditional logistic regression revealed that among ED patients the odds of having been previously diagnosed with migraines was 1.63 (95% CI, 1.39–1.91) that of the control group. This risk was more pronounced in younger groups, with the highest risk being detected among those aged between 30 and 39 years. After adjusting for the above mentioned comorbidities, ED patients aged between 30 and 39 years were found to be at 1.98 (95% CI, 1.67–2.23) times the risk of controls for having been previously diagnosed with migraines.

Conclusion: We conclude that ED is associated with having been previously diagnosed with migraines, particularly in younger populations.

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.

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.

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.

Risk of placental abruption in relation to migraines and headaches

Background

Migraine, a common chronic-intermittent disorder of idiopathic origin characterized by severe debilitating headaches and autonomic nervous system dysfunction, and placental abruption, the premature separation of the placenta, share many common pathophysiological characteristics. Moreover, endothelial dysfunction, platelet activation, hypercoagulation, and inflammation are common to both disorders. We assessed risk of placental abruption in relation to maternal history of migraine before and during pregnancy in Peruvian women.

Methods

Cases were 375 women with pregnancies complicated by placental abruption, and controls were 368 women without an abruption. During in-person interviews conducted following delivery, women were asked if they had physician-diagnosed migraine, and they were asked questions that allowed headaches and migraine to be classified according to criteria established by the International Headache Society. Logistic regression procedures were used to calculate odds ratios (aOR) and 95% confidence intervals (CI) adjusted for confounders.

Results

Overall, a lifetime history of any headaches or migraine was associated with an increased odds of placental abruption (aOR = 1.60; 95% CI 1.16-2.20). A lifetime history of migraine was associated with a 2.14-fold increased odds of placental abruption (aOR = 2.14; 95% CI 1.22-3.75). The odds of placental abruption was 2.11 (95% CI 1.00-4.45) for migraineurs without aura; and 1.59 (95% 0.70-3.62) for migraineurs with aura. A lifetime history of tension-type headache was also increased with placental abruption (aOR = 1.61; 95% CI 1.01-2.57).

Conclusions

This study adds placental abruption to a growing list of pregnancy complications associated with maternal headache/migraine disorders. Nevertheless, prospective cohort studies are needed to more rigorously evaluate the extent to which migraines and/or its treatments are associated with the occurrence of placental abruption.