Introduction
Migraine is a common primary form of headache (TH), which manifests itself in the form of repeated attacks, often accompanied by nausea, vomiting, photo- and phonophobia.
The prevalence of migraine, according to various estimates, ranges from 2.6% to 21.7%, and the average rate is 14.7% [1]. In Russia, the prevalence of migraine reaches 20.8%, which is approximately more than 30 million people [2]. The prevalence of migraine in women is more than 2 times higher than that in men, and the highest prevalence of migraine within the female population occurs during reproductive age [3]. For this reason, issues of tactics for managing patients with migraine during pregnancy are of high relevance. Issues of pregnancy planning, as well as rules for taking medications for pain relief and approaches to preventive treatment of migraine during pregnancy are discussed very often.
Treatment of headaches during pregnancy
Remember that most medications have a negative impact on the condition of the fetus. When you become pregnant, you can no longer take all the medications in a row as before. Pregnant women are advised to take paracetamol or Panadol to relieve pain. These medications are not harmful to the fetus. You can take a maximum of tablets per day. If you suffer from headaches, get enough rest.
Make sure that there is enough oxygen in your apartment and other rooms where you are. Sometimes sleeping for 20-30 minutes is enough to relieve pain. Watch your drinking regime. You need to drink one and a half liters of water or more per day. If the cause of your headache is hypotension, you can take a cup of natural coffee. The maximum per day should be 2 cups, no more. Otherwise, the headache may become even worse, and the condition of the fetus will not be the best.
If you are prone to hypertension, drink water and natural freshly squeezed juices. You should not drink less water in the 5-9th month, as some doctors advise. The body will still store water, and a lack of fluid with associated problems is guaranteed. Even if you have toxicosis, eat right to prevent headaches. Meals should be frequent, small portions. It's better to eat everything natural. You can take fruit, biscuits, yogurt, etc. with you for a walk.
Multivitamins for pregnant women are prescribed only when necessary. Gymnastics, acupressure, and neck massage can help relieve headaches. Yoga, meditation, and auto-training techniques are also recommended. If you feel a headache, do not rush to take pills. First, you can take a warm shower, and then put a cold compress on your head.
You should definitely tell your gynecologist about headaches. He may refer you to an osteopath or neurologist. After all, the cause may be a shift in the center of gravity and the resulting cervical osteochondrosis, which causes pain. Watch your posture when standing and sitting. Don't be in uncomfortable positions. Orthopedic pillows and mattresses are recommended for sleep.
The course of migraine during pregnancy
In 50–70% of women during pregnancy, migraine without aura improves [4]. Migraine attacks become mild, extremely rare, and in most patients in this group the migraine completely disappears. Improvement occurs after the first trimester, starting from the 12th–14th week. pregnancy. This is due to the fact that by the beginning of the second trimester, the level of estrogen stabilizes and begins to increase, and its fluctuations stop (Fig. 1). Migraine with aura stops less often during pregnancy, in approximately 40% of patients.
At the same time, if headache persists during this period, it is necessary to carry out differential diagnosis and determine the form of headache. Alarming symptoms during pregnancy are:
the appearance of a new, unusual headache;
a sharp increase in migraine attacks;
the addition of new, unusual symptoms of hypertension, including visual impairment, sensitivity, aphasia, paresis of the limbs;
the appearance of migraine aura in patients with previous migraine without aura;
increased blood pressure during hypertension;
convulsions.
The presence of active migraine during pregnancy does not affect the course of pregnancy itself and the development of the fetus, but increases the risk of preeclampsia and gestational hypertension. Moreover, the persistence of active migraine, especially migraine with aura, during pregnancy increases the risk of acute cerebrovascular accidents (ACVA) by 15–17 times [5]. The prevalence of stroke during pregnancy and the early postpartum period is 34.2 cases per 100,000 births [5].
In what cases is it recommended to abstain from intimacy:
- Placenta previa
- The presence of sexually transmitted diseases in the active phase in one or both parents (syphilis, gonorrhea, trichomoniasis, chlamydial infection, etc.). If HIV infection is detected in the expectant father, the pregnant woman is advised to refrain from unprotected sexual intercourse during pregnancy.
- Acute inflammatory process of the genital organs in one or both partners (before and during sanitation it is recommended to refuse sex).
- Symptoms indicating a threat of miscarriage: bleeding from the genital tract, pain in the lower abdomen, increased uterine tone, etc.
- A history of recurrent miscarriage or premature birth.
- If the pregnancy is multiple, sexual rest is recommended after 28 weeks to avoid premature birth.
- Leakage of amniotic fluid. If you suspect a water leak, you should immediately consult a doctor.
Stopping attacks
The selection of drug therapy for patients with migraine during pregnancy poses significant difficulties. The severity of migraines can be especially high during the first trimester. Full-blown, unrelieved migraine attacks are often accompanied by nausea, vomiting and lead to unnecessary suffering and dehydration, especially in patients suffering from early toxicosis. Despite the desire to avoid taking medications (especially in early pregnancy) to minimize the risk of fetal developmental disorders, many patients with hypertension begin to take analgesics uncontrollably. Therefore, the importance of preliminary counseling and education of patients on the proper control of hypertension cannot be overemphasized.
Non-pregnant women are recommended to take medications to relieve migraine attacks as early as possible, no later than 1 hour after the onset of the attack. This approach allows you to speed up relief and completely stop a migraine attack in a short time. Pregnancy is the only period in a woman’s life when this recommendation can be temporarily ignored. For patients seeking to minimize drug use, a stepwise approach may be recommended, in which treatment of mild to moderate attacks begins with non-drug methods.
If the patient decides not to use analgesics, control of nausea becomes a priority to avoid dehydration. Patients should avoid strong odors and drink more fluids, such as juices diluted 1:1 with water. Feelings of nausea can also be reduced by eating easily digestible foods, such as crackers, applesauce, bananas, rice, and pasta. Metoclopramide or ondansetron can also be used [6].
Neurostimulation methods play a major role in non-drug approaches to the treatment of migraine. The only device registered in Russia for non-invasive transcutaneous stimulation of the supraorbital nerve - Cefaly (Cefaly®) - is specially designed for the treatment of migraines and can be a good alternative to medications for relieving migraine attacks. Using the Cefaly device at the very beginning of an attack allows you to reduce the intensity of headaches and in some cases completely stop the attack. Thus, the intensity of migraine pain decreases by 4.3 points after 1 hour [7]. Cefaly can also be used in conjunction with pain medications to increase their effectiveness.
Despite the fact that, in general, paracetamol is less effective for relieving an acute attack of migraine than acetylsalicylic acid and nonsteroidal anti-inflammatory drugs (NSAIDs), its safety during pregnancy is higher [6]. Caffeine, which has the ability to enhance the analgesic effect, is an important addition to painkillers. Adding 100 mg of caffeine to the analgesic increases its effect by 1.5 times.
The safety of NSAIDs is controversial [6]. Prescribing NSAIDs in the first trimester may be associated with an increased risk of miscarriage and the development of congenital anomalies. Taking NSAIDs and aspirin in the third trimester can lead to premature closure of the ductus arteriosus
. For these reasons, the use of NSAIDs should be limited to the second trimester. It is especially important to stop taking them after the 32nd week. Taking high doses of aspirin may also increase the risk of bleeding.
Triptans are the most effective analgesics for the relief of migraine attacks. The safety of triptans during pregnancy is assessed through pregnancy registries, where a huge amount of data has now been accumulated for sumatriptan, for example. Despite the prohibition of its use during pregnancy indicated in the official instructions for the use of sumatriptan, there is no evidence of an increased risk of congenital malformations when taken by pregnant women [8]. Patients who took triptans in early pregnancy (without knowing they were pregnant) should be advised that the likelihood of adverse effects of this drug on the fetus is extremely low. Women who experience severe, disabling migraine attacks that cause vomiting may be advised to use triptans during pregnancy. To date, this information has not been included in official recommendations for the treatment of migraine, but the safety of sumatriptan is confirmed by the analysis of a huge number of observations and expert recommendations.
It should be borne in mind that the safety of triptans varies. Sumatriptan, as the most hydrophilic of the triptans, has difficulty penetrating the placental barrier, while other triptans (including eletriptan) are lipophilic.
Prednisolone can only be used as an “ambulance” remedy in the event of a prolonged and severe migraine attack [9]. The use of prednisolone is preferable to dexamethasone, since the latter penetrates the placenta better. Nuchal nerve blocks with lidocaine, bipuvacaine and/or a corticosteroid can be used as an ambulance to relieve severe attacks.
Benefits of sex during pregnancy:
- During sex, endorphins are produced - hormones of happiness. They are transmitted to the fetus through the blood, having a beneficial effect.
- During intimacy, muscle fibers contract, thereby training the uterus in preparation for childbirth.
- Seminal fluid contains prostaglandins, which contribute to the “ripening” of the cervix before childbirth.
- During sexual intercourse, blood supply to the pelvic organs is activated, and the baby’s nutrition improves.
- The psychological state of both parents will be much better if their usual life does not change for the worse. The desired woman will be calm about the relationship, and the man will not think about starting an affair on the side. You can try new sex positions, which will be a way for spouses to get bright emotions.
Negative effects of intimacy:
- If a woman has had miscarriages, sex can provoke an increase in uterine tone and termination of pregnancy.
- With isthmic-cervical insufficiency, the cervix shortens and the internal os opens slightly. Sex can cause progressive shortening of the cervix and lead to miscarriage or premature birth.
- Placenta previa is a good reason to refuse sex, because... The placenta is very low in the uterus, and during sex it can be detached with bleeding. In this case, there is a direct threat to the life of mother and baby.
- The presence of sexually transmitted infections in any of the partners during unprotected sexual intercourse can provoke infection of the amniotic fluid and infection of the baby.
- If you have sex too often without a condom, your microflora may be disrupted and thrush may develop. The fact is that sperm has an alkaline pH and when it enters the vagina, it reduces the acidity of the vaginal secretion, which promotes the growth of pathogenic bacteria and fungi.
Preventative treatment
The attending physician must promptly identify the group of patients in whom preventive treatment of migraine will be most successful. While most pregnant women begin migraine remission at the end of the first trimester, others experience migraine remission by the 10th–12th week. Frequent attacks may persist, which will most likely indicate the persistence of headache throughout pregnancy. Refusal to treat such patients can lead to malnutrition, dehydration, the development of affective disorders and a significant decrease in quality of life.
Preventive treatment of migraine is necessary in the following cases:
high frequency of attacks (more than 3 days a week);
the presence of severe or prolonged attacks;
significant disability;
dehydration and malnutrition;
poor response to analgesics.
The current frequency of headaches and the effectiveness of the analgesics used should be monitored using a headache diary. For patients who require preventive treatment, it is necessary to select the optimal combination of drug and non-drug approaches.
There are a number of non-drug methods that can effectively manage hypertension during pregnancy and are an important addition to pharmacological methods; when combined, the amount of drugs used during pregnancy and lactation is reduced. Relaxation techniques, cognitive behavioral therapy and biofeedback can be used during pregnancy.
Trigeminal neurostimulation also plays a major role in the preventive treatment of migraine during pregnancy. Regular use of Cefaly daily for 20 minutes, preferably in the evening, leads to a 2-fold reduction in migraine headache attacks in 38% of patients with episodic migraine and 35% of patients with chronic migraine [10, 11]. The high safety of this method (the probability of adverse events is 2–3%) allows it to be used without fear during pregnancy. It is also important that the Cefaly device has a mild sedative effect [12] and is not prohibited for use during pregnancy.
Information about the safety of drugs is collected through clinical trials of their use in the treatment of other diseases, including mood disorders, cardiovascular diseases and epilepsy. The safety of most drugs during pregnancy has not been directly assessed, but accumulated data have allowed these drugs to be assigned a certain safety category. In addition, the choice of drugs for the treatment of migraine in pregnancy may be based on additional information about the safety of a number of drugs that are used in pregnancy to treat hypertension, depression and epilepsy.
If it is necessary to prescribe drug therapy to reduce migraine attacks, it is recommended to start with the use of β-blockers. Due to its widespread use in the treatment of arterial hypertension during pregnancy, propranolol (anaprilin) is considered the drug of first choice for the preventive treatment of migraine [13]. At the same time, taking β-blockers is associated with a risk of hypoglycemia, hypotension, bradycardia and respiratory disorders in the newborn. The drug should also be used with caution in patients with bronchial asthma, a tendency to arterial hypotension and bradycardia. In the absence of propranolol or if there are contraindications to it, metoprolol can be used. It is recommended to gradually reduce the dose of beta-blockers during the last weeks of pregnancy (starting from the 36th week) and discontinue them at least 2-3 days before delivery.
No adverse effects on fetal development have been demonstrated with the use of calcium channel blockers, but insufficient data and the low effectiveness of verapamil do not allow it to be recommended for widespread use for the preventive treatment of migraine during pregnancy [13].
Lisinopril exhibits a teratogenic effect when used in the 2nd and 3rd trimesters and should be discontinued. Candesartan, which has a mechanism of action similar to lisinopril, should also not be used to treat migraine in pregnant women [14].
Despite the high effectiveness of antiepileptic drugs in the treatment of migraines, their use during pregnancy is prohibited. Valproic acid preparations are absolutely contraindicated during conception and pregnancy due to their teratogenic effect (disrupting the development of the fetal neural tube) and blood clotting disorders in the mother and fetus. In addition, data have accumulated on the possible teratogenic effects (development of hypospadias, cleft lip and palate) of topiramate [14].
Gabapentin has low effectiveness in the preventive treatment of migraine; the safety of its use during pregnancy has been poorly studied. Its use should be stopped in the third trimester due to its possible effect on bone development [6].
Tricyclic antidepressants are highly effective in the preventive treatment of migraine. Amitriptyline is relatively safe during this period and is the second choice drug for the preventive treatment of migraine [6, 13, 15].
The use of the serotonin and norepinephrine reuptake inhibitor venlafaxine in the third trimester increases the risk of developing behavioral syndrome of newborns by 3 times. Symptoms are usually mild in severity.
The safety of botulinum toxin type A preparations for the treatment of migraine during pregnancy has not been studied. At the same time, data have accumulated on the absence of teratogenic and embryotoxic effects of botulinum toxin type A in pregnant women who reported using the drug for various indications [16]. At the same time, the use of botulinum toxin for the preventive treatment of migraine during pregnancy is not recommended.
New drugs for the preventive treatment of migraine - antibodies to calcitonin gene-related peptide - erenumab and fremanezumab have not been studied for use in pregnant women and are not recommended for the treatment of migraine.
In addition to the above medications allowed during pregnancy, various vitamins and minerals can be mentioned. In particular, there is evidence of the benefits of magnesium for the preventive treatment of migraine during pregnancy [13, 15]. Pyridoxine (vitamin B6) at a dose of 80 mg/day alone or in combination with other drugs at a dose of 25 mg/day, for example with folic acid, can have a mild preventive effect against migraine.
Table 1 summarizes the safety data of the main groups of drugs used for the preventive treatment of migraine during pregnancy.
When should you see a doctor urgently?
Urgently go for a face-to-face consultation with your doctor if you experience severe headaches in combination with:
- convulsions
- weakness
- blurred vision
- loss of consciousness
- feeling of unreasonable fear
- intense pain in the pit of the stomach
- a sharp decrease in the volume of urine excreted
- sudden weight gain and increasing swelling
- nasal congestion plus headache in the forehead and eyes, toothache (the combination of such signs indicates sinusitis in a pregnant woman)
- muscle stiffness and feverish temperature
- nausea, vomiting and shortness of breath in the third trimester of pregnancy
- headache after you have injured your head in some way
- if you have a severe headache that cannot be relieved by anything
Treatment of headaches due to hypertension
So-called gestational hypertension appears after the 20th week of gestation. But in rare cases, an earlier appearance is possible. If you measured your blood pressure twice and got results of 140/90 mmHg. Art., this indicates hypertension (hypertension). You should be at rest 10 minutes before the measurement. When taking measurements, it is better to sit or lie on your left side to get reliable results.
Sometimes non-drug methods help and are safer for the fetus. You need to minimize any physical activity, reconsider your diet, quit smoking, drugs and alcohol. Record your blood pressure readings every day in a special diary. You can also note how you feel that day. If the pressure remains at a level of 150/90 mm Hg for a long time. Art., then the gynecologist will prescribe drug therapy. Recommended medications are nifedipine and dopegit.
For hypertension, switching to a salt-free diet and limiting the consumption of water and other drinks is NOT recommended. This can have dire consequences for the birth and the expectant mother.
Treatment of headaches in preeclampsia and eclampsia
Preeclampsia is a condition preceding eclampsia, which is dangerous for the fetus and the pregnant woman. The condition develops starting from the 20th week of gestation. Therapy is carried out in a hospital setting. The patient is given intravenous magnesium sulfate and other drugs to stabilize blood pressure. Sometimes they resort to premature delivery.
In order to detect and effectively treat preeclampsia in a timely manner, women at risk need to undergo a general blood and urine test once every 10 days, as well as monitor blood pressure levels.
Self-massage
This is one of the treatments for headaches in pregnant women. You should not do it if you have hypertension (pressure from 150/90 mm Hg), severe hair loss, or pustular lesions of the scalp. If you use this method and the condition gets worse, then do not use it in the future.
Perform the movements vigorously, pressing your fingers tightly to the scalp. Do the massage for no more than 15 minutes. With your thumbs and forefingers, you need to grab the skin in the area of the brow ridges into folds and lightly squeeze. Then they repeat the same thing, with gradual advancement to the temples from the center. The temples need to be kneaded in a circular motion, pressing on them with your fingertips.
Next technique: close your palm and stroke from the eyebrow arches to the hairline. Combing your hair in different directions from the crown and kneading the parting with your fingertips also helps. Next, make a parting in another place and repeat what you did. You can knead the hair-covered scalp area with the entire brush.
Next technique: grab your head on both sides, spread your fingers, move and push the skin in opposite directions. Neck massage is also effective for headaches, but do not apply too much pressure.
