Options While Pregnant

Start with options that do not expose the fetus to chemicals

There are five FDA approved electronic devices to treat migraine (Cefaly, Nerivio, Gammacore Sapphire, Relivion, and SAVI Dual.  3 of them have been demonstrated in controlled studies for migraine prevention as well.  The electronic devices that have been proven to prevent migraine (Cefaly, Nerivio, and Gammacore) headache have not been proven “safe for pregnancy” because they have not been formally testing in pregnancy.  However, it is hard to imaging how activating the nervous system as these devices do would harm a developing fetus. All of these devices work by stimulating a nerve in the body and the fetus itself is far removed from the electrical impulse.  The downside of these devices is they are relatively expensive compared to other options and they are relatively slow in prevention.  The devices can also be relatively expensive and generally not covered by insurance.

During the first trimester, Dr. Loftus is most comfortable with both triptans and NSAIDs.  Beyond 20 weeks, NSAID should not be used and triptans are less clear.  This is when the electronic devices are most helpful.

Preventative treatments to consider

Combined trigeminal and occipital nerve blocks has virtually no exposure to a fetus during pregnancy.  Very little medication gets into the veins and this is metabolized by the liver.

SPG block, with a deep device like Sphenocath®, appears to give both acute treatment and preventative treatment in patients with migraine.  There are no well controlled studies to estimate its chance of working but it does work in some patients.  Risk of nausea with vomiting seems to be somewhat higher than the 1-2% typically quoted.

Intermittent IV magnesium sulfate for migraine prevention is not well studied in patients but is clearly safe in the third trimester.  At our practice, we typically use IV magnesium sulfate 1 gram in 50 cc normal saline injected weekly over 5-6 minutes.  Since IV magnesium is used during pre-eclampsia to prevent seizures in women before delivery, this dose is known to be completely safe.  Total dosing from the third trimester on would therefore be 13 grams or less.  This is less than 1 day of IV magnesium exposure during pre-eclampsia.

For high frequency migraines, Botulinum toxin, can be used.  This is typically covered by insurance for more than 15 headache days per month.  In our practice, it is about 6 times more expensive than the nerve blocks mentioned above.  While use during pregnancy is not FDA approved, it is thought by most headache specialist to be safe.  We have limited data for women who took Botox by accident during pregnancy.  We also have data from women who had botulism (the disease with very high levels of botulinum toxin)  during pregnancy.  The Botox molecule is too large to cross the placenta.  Those headache specialist uncomfortable with its use are most uncomfortable with the specific risk of law suits.