Treatment Options When Trying to Conceive

There are no risk and very low risk options for the fetus

Preventative Treatments With Zero or Near Zero Risk to fetus

There are five FDA approved electronic devices to treat migraine. They are named Cefaly, Nerivio, gammaCore Sapphire, Relivion, and SAVI Dual.  Three of them have been shown, in controlled studies, to also be effective for migraine prevention as well. They are Cefaly, Nerivio, and gammaCore Sapphire.

The electronic devices that have been proven to prevent migraine  headache have not been proven “safe for pregnancy” because they have not been formally tested 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 to work in prevention.  Therefore starting them earlier prior to pregnancy is more effective than starting later.  The devices are generally not covered by insurance so they are typically a more expensive option.

Working much faster than the electronic devices is the combined trigeminal and occipital nerve block as initially recommended by Dr. Kaneicki.  While neurologist had been using nerve blocks for decades, the unique steroid free, 10 injection sites per occipital nerve allowed this treatment to be used for prevention.  It works well 50% of the time and when it works, it typically works in a day or two.  Infrequently, it takes up to 2 weeks to work.  Typically bupivacaine is used for the anesthetic but if a woman is in her first trimester, than lidocaine is used.  Lidocaine is considered safe for pregnancy but no matter what is used, the exposure of the fetus is essentially zero.  Only some of the medication makes it into the venous system and then most would be metabolized before it would get to a developing fetus.

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.  The benefit for conception is that the medication only lasts in the body for a few days post injection but its benefits last about 12 weeks.

Another option for prevention is intermittent IV magnesium sulfate injections.  Since this off label, their is no established best method.  Dr. Loftus does believe that relatively rapid infusion such as magnesium sulfate 1 gram in 50 cc normal saline over 5-6 minutes is better than the same dose given one an hour.  It is initially used weekly for 4-6 weeks to see how effective it can be.  Then, it is common for Dr. Loftus to reduce the frequency to every other week.  Dr. Loftus will almost always stop this treatment once pregnant (testing before each administration when a woman could be pregnant) given the lack of safety data in early pregnancy.

For acute treatment without fetal chemical exposure, the electronic devices and self-relaxation therapy procedures are the only options.

Low risk options with fetal exposure

There are generally 3 classes or oral preventatives for migraines.  Using antidepressants for prevention how mixed data for pregnancy.  For this reason, I typically do not use this class unless there is a medical reason why it needs to be used.  Beta blockers early in pregnancy are felt to be safe.  Later in pregnancy can be an issue so I generally stop it after the first trimester.  Of the seizure medications that can be used for migraine prevention, topiramate, zonisamide, and divalproex, only zonisamide appears safe according to the North American AED registry for pregnancy.  With limited data, accidental pregnancies during studies for diabetic retinopathy with candesartan versus placebo has not shown increase risk when the drug was discontinued prior to the third trimester.

Triptans are felt to be clearly safe during the first trimester of pregnancy.  After the first trimester, the data is less clear and less well studied.  If there is increased risk, it is probably small.  NSAIDs can be used until week 20.  After this time, it can cause problems with the fetus.  Dr. Loftus is more comfortable with triptans during the first trimester than NSAIDs.