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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.
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