Clinical Provider Survey Reveals Varied Levels of Comfort for Migraine Treatment During Pregnancy

Allison Verhaak, PhD

In a recent survey study of 92 women's healthcare providers, 91% of whom specialized in general obstetrics and gynecology, findings revealed varying levels of comfort regarding migraine management during pregnancy. Results highlight areas where additional headache medicine education would likely be beneficial in women's healthcare and support the continued need for treatment standardization for migraine during pregnancy.

Approximately 26% of all respondents reported they counseled women on migraine treatment during pregnancy before pregnancy contemplation, while over 35% counseled for migraine treatment once the patient became pregnant. Respondents indicated feeling somewhat or very comfortable with recommending (63%) or continuing (64%) acute treatments for pregnant patients with migraine. Highest comfort levels were reported for recommending of prescribing acetaminophen (100%) and prescribing (94% [85 of 90]) or continuing caffeine (91% [82 of 90]).

“Migraine treatment during pregnancy can be challenging for many reasons, including risks associated with certain medications and lack of clinical trials,” lead author Allison Verhaak, PhD, clinical psychologist, Ayer Neuroscience Institute, Hartford Healthcare Headache Center, told NeurologyLive^®. “We know that some women receive all aspects of care, including primary care, obstetrical/gynecological, and migraine care, from their women’s healthcare provider, but we know very little about how these women’s healthcare providers approach migraine treatment during pregnancy.”

The online survey was distributed to selected women’s healthcare providers in Connecticut and expanded on a survey done by American Headache Society (AHS) members.² Different levels of preventive and acute migraine treatment were included in the survey such as recommending or prescribing versus continuing specific treatments. In addition, the survey had questions related to comfort and frequency with recommending or prescribing or continuing triptans for migraine during pregnancy.

“Migraine is most common for women during the reproductive years, with previous studies suggesting a prevalence around 25% in women aged 30-39. Up to 80% of these women will continue to have migraine at some point in their pregnancy. Although many women report improvements in migraine during pregnancy, particularly by the second trimester, up to 60% may not see improvements of migraine during pregnancy, and thus, treatment during this time is very important,” Verhaak noted.

Eighty-eight percent (n = 80) out of 91 respondents reported higher levels of discomfort with recommending or prescribing triptans during pregnancy for migraine. Additionally, 40% respondents felt less comfortable with recommending preventive migraine treatments to pregnant patients, in comparison with 63% being somewhat or very comfortable with continuing preventive medications.

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“Interestingly, years of safety data for triptans (particularly sumatriptan) do not appear to show adverse outcomes in pregnancy; however, the American College of Obstetrics and Gynecology recently released treatment guidelines of headache during pregnancy, and encouraged ‘cautious’ use of sumatriptan for secondary treatment of persistent headache in pregnancy,” Verhaak noted. “Once again, this highlights the complexity of migraine treatment during pregnancy, including differing comfort levels across specialties and challenges of relying on safety data.”

Sixty-nine out of 91 respondents felt higher comfort levels with prescribing use of magnesium whereas 82% felt comfortable for continuing medication. Notably, 70% (n = 62) of 89 respondents felt comfortable prescribing nonpharmacologic approaches whereas 84% felt comfortable continuing with the treatment method. Approximately 40% of the total respondents indicated that they normally referred to neurologists or headache specialists for migraine treatment during pregnancy.

Results may not be generalizable to other geographic regions, clinical settings, or providers because of the respondents being from specific clinical locations in Connecticut. Also, it was not possible to determine the final response rate for the survey as recruitment was through wide email sends to institutions or clinics. Survey questions had no option for nuanced responses regarding comfort with specific acute and preventive treatments, hence, different results may have been observed if it was included.

Verhaak noted, “With these results, we are hoping to help bridge the knowledge, comfort, and treatment gaps between different medical specialties who may care for patients with migraine during pregnancy, with the ultimate goal of increasing cross-disciplinary conversations and standardized care for this important patient population.”

REFERENCES
1. Verhaak A, Bakaysa S, Johnson A, Veronesi M, Williamson A, Grosberg B. Migraine treatment in pregnancy: A survey of comfort and treatment practices of women's healthcare providers. Headache. 2023;10.1111/head.14436. doi:10.1111/head.14436
2. Hamilton KT, Halker Singh RB, Ailani J, Butterfield RJ, Robbins MS. Migraine Treatment in Pregnancy: An American Headache Society Survey. Headache. 2020;60(10):2594-2596. doi:10.1111/head.13974