Migraine management during pregnancy, breastfeeding and in women planning pregnancy.

Raffaele Ornello, Antoinette Maassen van den Brink, Francesca Puledda, Claire H Sandoe, Luigi Francesco Iannone, Nadine Pelzer, Mi Ji Lee, Faraidoon Haghdoost, Laura Gomez-Dabo, Patricia Pozo-Rosich, Teshamae S Monteith, Cristina Tassorelli, Gisela M Terwindt, Simona Sacco

Journal: Cephalalgia : an international journal of headache 2025;45(11):3331024251393945

PMID: 41263702

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Abstract

Migraine is a common neurological disorder that predominantly affects women during their reproductive years, presenting unique challenges in the context of pregnancy, breastfeeding, and pregnancy planning. In the present review, we intend to summarize those challenges and propose possible solutions. Women with migraine, particularly those with aura, face an increased risk of pregnancy-related complications, including preeclampsia, stroke, and preterm birth, highlighting the need for careful monitoring throughout gestation. When migraine persists during pregnancy, management should prioritize non-pharmacological approaches, with a strong emphasis on lifestyle modifications and behavioral therapies. In some settings, non-invasive neuromodulation may also be a reasonable option. However, disabling migraine should not be left untreated and may require pharmacological management. Pharmacological treatments should be chosen primarily based on safety considerations, as many migraine medications are not suitable for use during pregnancy. Given the limited safety data available for several treatments, shared decision-making between patients and healthcare providers is essential. During breastfeeding, medication selection should focus on minimizing infant exposure while ensuring effective migraine control for the mother. In women of childbearing potential, caution is needed when prescribing certain migraine treatments, as unplanned pregnancies can occur. Special considerations should also be given to those requiring preventive treatment while planning pregnancy. Given the complexities of migraine management in this population, an individualized approach is crucial to balancing maternal well-being with fetal and infant safety.

Address: Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy.; Division of Pharmacology and Vascular Medicine, Department of Internal Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands.; Headache Group, Wolfson SPaRC, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.; Women's College Hospital, Division of Neurology, University of Toronto, Toronto, Canada.; Department of Specialist Medicines, Digital and Predictive Medicine, Pharmacology and Clinical Metabolic Toxicology-Headache Center and Drug Abuse, Laboratory of Clinical Pharmacology and Pharmacogenomics, AOU Policlinico di Modena, Modena, Italy.; Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy.; Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands.; Department of Public Health and Primary Care, Health Campus the Hague, Leiden University Medical Centre, the Hague, the Netherlands.; Department of Neurology, Seoul National University Hospital, Seoul, Republic of Korea.; Department of Neurology, Seoul National University College of Medicine, Seoul, Republic of Korea.; The George Institute for Global Health, University of New South Wales, Sydney, Australia.; Headache Unit, Neurology Department, Hospital Universitari Vall d'Hebron; Headache & Neurological Pain Research Group, Vall d'Hebron Institute of Research, Barcelona, Spain.; Department of Neurology- Headache Division, University of Miami, Miller School of Medicine, Miami, Florida, USA.; Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy.; Headache Science & Neurorehabilitation Center, IRCCS Mondino Foundation, Pavia, Italy.; Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands.

DOI: 10.1177/03331024251393945

MeSH Terms: Humans, Female, Pregnancy, Breast Feeding, Migraine Disorders, Pregnancy Complications, Family Planning Services