Knowledge and Comfort in Treating Migraine During Pregnancy

Allison Verhaak, PhD

Studies show that migraine is associated with several maternal and fetal health complications during pregnancy. Treating migraine during this period can be difficult because of the lack of clinical trials investigating the risks related to specific treatments. Allison Verhaak, PhD, and colleagues, recently had a published survey study of 92 women's healthcare providers where results identified a variety of comfort levels for migraine care during pregnancy.¹

Of all respondents (n = 92), approximately 26% reported (n = 28) they counseled women on migraine treatment during pregnancy before pregnancy contemplation, while over 35% counseled for migraine treatment at pregnancy conception. Respondents reported feeling somewhat or very comfortable with recommending (63%) or continuing (64%) acute treatments for pregnant patients with migraine. Highest comfort levels were indicated for recommending of prescribing acetaminophen (100%) and prescribing (94% [85 of 90]) or continuing caffeine (91% [82 of 90]).¹

In a recent interview with NeurologyLive^®, Verhaak, clinical psychologist, Ayer Neuroscience Institute, Hartford Healthcare Headache Center, discussed the motivations for the investigation as well as the main findings observed. She provided a brief background summary on migraines during pregnancy and the methods of conducting the survey. Additionally, she mentioned the next steps for her team in terms of educational awareness based on the survey’s results.

NeurologyLive^®: What was the motivation for conducting this research?

Migraine treatment during pregnancy can be challenging for many reasons, including risks associated with certain medications and lack of clinical trials. 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. We wanted to explore migraine treatment practices of women’s healthcare providers, particularly in comparison to other research highlighting how headache specialists might care for migraine during pregnancy.

How common is migraine for women 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.

How generalizable are the results, was the survey nationwide?

We sent an online survey to over 400 women’s healthcare providers in Connecticut, and received nearly 100 responses, primarily from providers who described themselves as specializing in obstetrics and gynecology.

What were the key findings and highlights of the survey?

The key findings from this study were the differences and similarities in treatment practices between women’s healthcare providers from our study, and another study which surveyed headache specialists about treatment of migraine during pregnancy. More specifically, our women’s healthcare providers reported feeling largely uncomfortable with prescribing or recommending use of nerve block injections or neuromodulation devices for migraine treatment during pregnancy, while headache specialists reported feeling primarily comfortable with these treatments. This highlights different comfort levels between medical specialties which may be treating migraine during pregnancy, and emphasizes the importance of cross-specialty education, consulting, and creation of standardized treatment guidelines.

Another interesting finding is that women’s healthcare providers reported feeling largely uncomfortable with prescribing triptans during pregnancy (a level-A treatment for migraine), and this was in agreement with the reported comfort of headache specialists in another survey.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.Once again, this highlights the complexity of migraine treatment during pregnancy, including differing comfort levels across specialties and challenges of relying on safety data.

Finally, over one-third (35%) of women’s healthcare providers reported that they counsel patients on migraine treatment during pregnancy AFTER the patient has already become pregnant. This may prove challenging for both the patient and the provider, as many migraine treatments and medications may not be safe for the patient to take during pregnancy, and sooner planning is strongly encouraged.

With the survey results in mind, what is the next step for your team?

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. We are very fortunate to have such multidisciplinary research collaborations across Hartford Healthcare medical specialties, with Stephanie Bakaysa, MD, a specialist in maternal fetal medicine, and Amy Johnson, MD, a specialist in obstetrics and gynecology, as co-authors on this research study. The study was published online by Headache: The Journal of Head and Face Pain in January 2023, and other study co-authors include Maria Veronesi, MA, Anne Williamson, PhD, and Headache Center director Brian Grosberg, MD.

Transcript edited for clarity.

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