Skip to main content Accessibility help
Hostname: page-component-7ccbd9845f-jxkh9 Total loading time: 0.993 Render date: 2023-01-28T17:23:42.214Z Has data issue: true Feature Flags: { "useRatesEcommerce": false } hasContentIssue true

12 - Approach to Pregnant or Lactating Patients with Headache in the Emergency Department

Published online by Cambridge University Press:  09 October 2017

Serena L. Orr
Children’s Hospital of Eastern Ontario, Ottawa
Benjamin W. Friedman
Albert Einstein College of Medicine, New York
David W. Dodick
Mayo Clinic, Phoenix, AZ
Get access



Most pregnant women with migraine improve during pregnancy, though migraine can resume following delivery and during breastfeeding. Since many women limit their exposure to drugs during pregnancy or breastfeeding, a migraine may be undertreated, become severe, refractory, and result in the need for an emergency department (ED) visit during this period. As with non-pregnant women, early management requires differentiation between primary and secondary headache, and though most headaches evaluated in the ED are migraines, some patients will need imaging or specialty consultation for this determination. Drug safety during pregnancy and lactation will limit the use of some drugs used in the treatment of migraine. Medications for acute treatment of refractory migraine in pregnant or lactating women are discussed and include dopamine antagonists, nonsteroidal anti-inflammatory medications, magnesium, opioids, triptans, and corticosteroids. Recommendations for medication use are made on the basis of risk of the drug to a pregnant woman or nursing infant and evidence for efficacy in the ED population.

Emergency Headache
Diagnosis and Management
, pp. 125 - 140
Publisher: Cambridge University Press
Print publication year: 2017

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)


1.Lipton, RB, Bigal, ME. The epidemiology of migraine. Am J Med. 2005;118(Suppl. 1):3S–10S.Google ScholarPubMed
2.Nappi, RE, Albani, F, Sances, G, et al. Headaches during pregnancy. Curr Pain Headache Rep. 2011;15:28994.CrossRefGoogle ScholarPubMed
3.Hoshiyama, E, Tatsumoto, M, Iwanami, H, et al. Postpartum migraines: a long-term prospective study. Intern Med. 2012;51:3119–23.CrossRefGoogle ScholarPubMed
4.Ertresvag, JM, Swart, JA, Helde, G, et al. Headache and transient neurological symptoms during pregnancy, a prospective cohort. Acta Neurol Scand. 2005;111:233–7.CrossRefGoogle ScholarPubMed
5.Melhado, EM, Maciel, JA, Guerreiro, CM. Headache during gestation: evaluation of 1101 women. Can J Neurol Sci. 2007 ;34:187–92.Google ScholarPubMed
6.Fiesseler, FW, Riggs, RL, Shih, R, Richman, PB. Do patients with recurrent headaches attempt abortive therapy before their emergency department visit? J Emerg Med. 2007;32:245–8.CrossRefGoogle ScholarPubMed
7.Klapper, JA, Stanton, JS. Current emergency treatment of severe migraine headaches. Headache. 1993;33:560–2.CrossRefGoogle ScholarPubMed
8.Marcus, D. Managing headache during pregnancy and lactation. Expert Rev Neurotherapeutics. 2008;8:385–95.CrossRefGoogle ScholarPubMed
9.Treadwell, SD, Thanvi, B, Robinson, TG. Stroke in pregnancy and the puerperium. Postgrad Med J. 2008;84:238–45.CrossRefGoogle ScholarPubMed
10.Heit, J, Kobbervig, C, James, A, et al. Trends in the incidence of deep vein thrombosis and pulmonary embolism during pregnancy or the puerperium: a 30-year population-based study. Ann Int Med. 2005;143:697706.CrossRefGoogle ScholarPubMed
11.James, AH, Bushnell, CD, Jamison, MG, Meyers, ER. Incidence and risk factors for stroke in pregnancy and the puerperium. Obstet Gynecol. 2005;106:50616.CrossRefGoogle ScholarPubMed
12.Report of the national high blood pressure education program working group on high blood pressure in pregnancy. Am J Obstet Gynecol. 2000;183:S1–S22.
13.Adeney, KL, Williams, MA. Migraine headaches and preeclampsia: an epidemiologic review. Headache. 2006;46:794803.CrossRefGoogle Scholar
14.Bushnell, CD, Jamison, M, James, AH. Migraines during pregnancy linked to stroke and vascular disease in a US population based case control study. BMJ. 2009;10:338.Google Scholar
15.Facchinetti, F, Allais, G, Nappi, RE, et al. Migraine is a risk factor of hypertensive disorders in pregnancy: a prospective cohort study. Cephalalgia. 2009;29:286–92.CrossRefGoogle ScholarPubMed
16.Williams, MA, Peterlin, BL, Gelaye, B, et al. Trimester-specific blood pressure levels and hypertensive disorders among pregnant migraineurs. Headache. 2011;51:1468–82.CrossRefGoogle ScholarPubMed
17.Marcoux, S, Berube, S, Brissan, J, Fabia, J. History of migraine and risk of pregnancy-induced hypertension. Epidemiology. 1992;3:53–6.CrossRefGoogle ScholarPubMed
18.Adeney, KL, Williams, MA, Miller, RS, et al. Risk of pre-eclampsia in relation to maternal history of migraine headaches. J Matern Fetal Neonatal Med. 2005;18:167–72.CrossRefGoogle ScholarPubMed
19.American College of Obstetricians and Gynecologists. Chronic hypertension in pregnancy: ACOG Practice Bulletin no.125. Obstet Gynecol. 2012;119:396407.CrossRefPubMed
20.Deak, TM, Moskovitz, JB. Hypertension and pregnancy. Emerg Med Clin North Am. 2012;30:90317.CrossRefGoogle Scholar
21.Robbins, MS, Farmakidis, C, Dayal, AK, Lipton, RB. Acute headache diagnosis in pregnant women: a hospital-based study. Neurology. 2015;85:1024–30.CrossRefGoogle ScholarPubMed
22.Ramchandren, S, Cross, BJ, Liebeskind, DS. Emergent headaches during pregnancy: correlation between neurologic examination and neuroimaging. Am J Neuroradiol. 2007;28:1085–7.CrossRefGoogle ScholarPubMed
23.ACR-SPR practice parameter for imaging pregnant or potentially pregnant adolescents and women with ionizing radiation. Resolution 39, amended 2014.
24.The American College of Obstetricians and Gynecologists. The American College of Obstetricians and Gynecologists women’s health care physicians guidelines for diagnostic imaging during pregnancy and lactation; no. 656, February 2016.
25.Ephross, SA, Sinclair, SM. Final results from the 16-year sumatriptan, naratriptan, and Treximet pregnancy registry. Headache. 2014;54:1158–72.CrossRefGoogle ScholarPubMed
26.Nezvalova-Henriksen, K, Spigset, O, Nordeng, H. Triptan exposure during pregnancy and the risk of major congenital malformations and adverse pregnancy outcomes: results from the Norwegian mother and child cohort study. Headache. 2010;50:563–75.CrossRefGoogle ScholarPubMed
27.Balbin, JEB, Nerenberg, R, Baratloo, A, Friedman, BW. Intravenous fluids for migraine: a post hoc analysis of clinical trial data. Am J Emerg Med. 2016;34(4):713–16.CrossRefGoogle ScholarPubMed
28.Rozen, TD. Emergency department and inpatient management of status migrainosus and intractable headache. Continuum. 2015;21:1004–17.Google ScholarPubMed
29.FDA. Pregnancy categories for prescription drugs. FDA Drug Bulletin. 1982;12:24–5.PubMed
30.Koren, G, Pastuszak, A, Ho, S. Drugs in pregnancy. N Engl J Med. 1998;338:1128–37.CrossRefGoogle ScholarPubMed
31.Kelley, NE, Tepper, DE. Rescue therapy for acute migraine: Part 3. Opioids, NSAIDs, steroids, and post-discharge medications. Headache. 2012;52:467–82.CrossRefGoogle ScholarPubMed
32.Anderson, G. Using pharmacokinetics to predict effects of pregnancy and maternal–infant transfer of drug during lactation. Expert Opin Drug Metab Toxicol. 2006;2:947–60.CrossRefGoogle ScholarPubMed
33.Peroutka, SJ, Snyder, SH. Relationship of neuroleptic drug effects at brain dopamine, serotonin, adrenergic and histamine receptors to clinical potency. Am J Psychiatry. 1980;137:1518–22.Google ScholarPubMed
34.Parlak, I, Atilla, R, Cicek, M, et al. Rate of metoclopramide infusion affects the severity and incidence of akathisia. Emerg Med J. 2005;22:621–4.CrossRefGoogle ScholarPubMed
35.Wijemanne, S, Jankovic, J, Evans, RW. Movement disorders from the use of metoclopramide and other antiemetics in the treatment of migraine. Headache. 2016;56:153–61.CrossRefGoogle Scholar
36.Cete, Y, Dora, B, Ertan, C, Ozdemir, C, Oktay, C. A randomized prospective placebo-controlled study of intravenous magnesium sulphate vs. metoclopramide in the management of acute migraine attacks in the emergency department. Cephalalgia. 2005;25:199204.CrossRefGoogle ScholarPubMed
37.Friedman, BW, Bender, B, Davitt, M, et al. A randomized trial of diphenhydramine as prophylaxis against metoclopramide-induced akathisia in nauseated emergency department patients. Ann Emerg Med. 2009;53:379–85.CrossRefGoogle ScholarPubMed
38.Momma, K, Hagiwara, H, Konishi, T. Constriction of fetal ductus arteriosus by non-steroidal anti-inflammatory drugs: study of additional 34 drugs. Prostaglandins. 1984;28:527–36.CrossRefGoogle ScholarPubMed
39.Daniel, S, Koren, G, Lunenfeld, E, et al. Fetal exposure of nonsteroidal anti-inflammatory drugs and spontaneous abortions. CMAJ. 2014;186:E177–82.CrossRefGoogle ScholarPubMed
40.Amundsen, S, Nordeng, H, Nezalova-Henriksen, K, Stovner, LJ, Spigset, O. Pharmacological treatment of migraine during pregnancy and breastfeeding. Nat RevNeurol. 2015;11:209–19.Google ScholarPubMed
41.Riaz, M, Porat, R, Brodsky, NL, Hurt, H. The effects of maternal magnesium sulfate treatment on newborns: a prospective controlled study. J Perinatol. 1998;18:449–54.Google ScholarPubMed
42.Langer-Gould, AM, Anderson, WE, Armstrong, MJ et al. The American Academy of Neurology’s top five choosing wisely recommendations. Neurology. 2013;81(11);1004–11.CrossRefGoogle ScholarPubMed
43.Cooper, J, Jauniaux, E, Gulbis, B, Quick, D, Bromley, L. Placental transfer of fentanyl in early human pregnancy and its detection in fetal brain. Br J Anaesth. 1999;82:929–31.CrossRefGoogle ScholarPubMed
44.Soldin, OP, Dahlin, J, O’Mara, DM. Triptans in pregnancy. Ther Drug Monit. 2008;30:59.CrossRefGoogle ScholarPubMed
45.Evans, EW, Lorbe, KC. Use of 5-HT agonists in pregnancy. Ann Pharmacother. 2008;42:543–9.CrossRefGoogle ScholarPubMed
46.Loder, E. Safety of sumatriptan in pregnancy: a review of the literature so far. CNS Drugs. 2003;17:17.CrossRefGoogle ScholarPubMed
47.O’Quinn, S, Ephross, SA, Williams, V, et al. Pregnancy and perinatal outcomes in migraineurs using sumatriptan: a prospective study. Arch Gynecol Obstet. 1999;263:712.CrossRefGoogle ScholarPubMed
48.Shuhaiber, S, Pastuszak, A, Schick, B et al. Pregnancy outcome following first trimester exposure to sumatriptan. Neurology. 1998;51:581–3.CrossRefGoogle ScholarPubMed
49.Schenker, S, Yang, Y, Perez, A, et al. Sumatriptan (Imitrex) transport by the human placenta. Proc Soc Exp Biol Med. 1995;210:213–20.CrossRefGoogle ScholarPubMed
50.Guputa, S, Hanff, LM, Visser, W, et al. Functional reactivity of 5-HT receptors in human umbilical cord and maternal subcutaneous fat arteries after normotensive or pre-eclamptic pregnancy. J Hypertens. 2006;24:1345–53.Google Scholar
51.Innes, GD, Macphail, I, Dillon, EC, Metcalfe, C, Gao, M. Dexamethasone prevents relapse after emergency department treatment of acute migraine: a randomized clinical trial. CJEM. 1999;1:2633.CrossRefGoogle ScholarPubMed
52.Colman, I, Freidman, BW, Brown, MD, et al. Parenteral dexamethasone for acute severe migraine headache: meta-analysis of randomized controlled trials for preventing recurrence. BMJ. 2008;336:1359–61.CrossRefGoogle ScholarPubMed
53.Orr, SL, Aubé, M, Becker, WJ, et al. Canadian Headache Society systematic review and recommendations on the treatment of migraine pain in emergency settings. Cephalalgia. 2015;35:271–84.CrossRefGoogle ScholarPubMed
54.Begg, EJ, Duffull, SB, Hackett, LP, et al. Studying drugs in human milk: time to unify the approach. J Hum Lact. 2002;18:323–32.CrossRefGoogle ScholarPubMed
55.Larsen, LA, Ito, S, Koren, G. Prediction of milk/plasma concentration ratio of drugs. Ann Pharmacother. 2003;37:1299–300.CrossRefGoogle ScholarPubMed
56.Atkinson, HC, Begg, EJ. Prediction of drug distribution into human milk from physicochemical characteristics. Clin Pharmacokinet. 1990;18:151–67.CrossRefGoogle ScholarPubMed
57.Riant, P, Urien, S, Albengres, E, et al. High plasma protein binding as a parameter in the selection of betablockers for lactating women. Biochem Pharmacol. 1986;35:4579–81.CrossRefGoogle ScholarPubMed
58.American Academy of Pediatrics Committee on Drugs. Transfer of drugs and other chemicals into human milk. Pediatrics. 2001 ;108:776–89.PubMed
60.Hale, TW. Medications and Mothers’ Milk. Amarillo, TX: Hale Publishing; 2008.Google Scholar
62.Hutchinson, S, Marmura, MJ, Calhoun, A, et al. Use of common migraine treatments in breast-feeding women: a summary of recommendations. Headache. 2013;53:114.CrossRefGoogle ScholarPubMed
63.Kauppila, A, Arvela, P, Koivisto, M, et al. Metoclopramide and breast feeding: transfer into milk and the newborn. Eur J Clin Pharmacol. 1983;25:819–23.CrossRefGoogle ScholarPubMed
64.Wischnik, A, Manth, SM, Lloyd, J, Bullingham, R, Thompson, JS. The excretion of ketorolac tromethamine into breastmilk after multiple oral dosing. Eur J Clin Pharmacol. 1989;36:521–4.CrossRefGoogle Scholar
65.Cruikshank, DP, Varner, MW, Pitkin, RM. Breast milk magnesium and calcium concentrations following magnesium sulfate treatment. Am J Obstet Gynecol. 1982;143:685–8.CrossRefGoogle ScholarPubMed
66.Wojnar-Horton, RE, Hackett, LP, Yapp, P, et al. Distribution and excretion of sumatriptan in human milk. Br J Clin Pharmacol. 1996;41:217–21.CrossRefGoogle ScholarPubMed
67.Trainor, A, Milner, J. Pain treatment and relief among patients with primary headache subtypes in the ED. Am J Emerg Med. 2008;26:1029–34.CrossRefGoogle ScholarPubMed
68.Broussard, CS, Rasmussen, SA, Reefhuis, J, et al. Maternal treatment with opioid analgesics and risk for birth defects. Am J Obstet Gynecol. 2011;204:314.e1–11.CrossRefGoogle ScholarPubMed
69.Einarson, A, Maltepe, C, Narioz, Y, et al. The safety of ondansetron for nausea and vomiting of pregnancy: a prospective comparative study. BJOG. 2004;111:940–3.CrossRefGoogle ScholarPubMed

Save book to Kindle

To save this book to your Kindle, first ensure is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about saving to your Kindle.

Note you can select to save to either the or variations. ‘’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Available formats

Save book to Dropbox

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Dropbox.

Available formats

Save book to Google Drive

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Google Drive.

Available formats