SSRIs: where are we now?
Jill is a 26-year-old secretary who has suffered from migraines since the age of 11. She is now in her 16th week of pregnancy and is disappointed that her headaches have not subsided. She asks what else she can take apart from paracetamol. Dr Tanvir Jamil discusses.
Can you remind me of the diagnostic criteria?
•Repeated attacks of headache lasting four to 72 hours
•At least two of: unilateral pain; throbbing pain; aggravation by movement; moderate or severe intensity
•At least one of: nausea/vomiting; photobia and phonophobia
So if a patient satisfies the above criteria and there are no other clinical signs then the patient almost certainly has migraine and further investigation is not warranted.
Almost 20 per cent of women suffer from migraines – especially in the child-bearing years. It is thought to be related to oestrogen levels before menstruation. When the symptoms appear regularly at the onset of menses the condition is called menstrual migraine.
What is the course of migraine during pregnancy?
Most women with migraine improve during pregnancy. A study from Italy in 2003 found migraine improved in about 47 per cent of sufferers during the first trimester, in 83 per cent during the second and in 87 per cent during the third. Complete remission was attained by almost 11 per cent, 53 per cent, and 79 per cent of the women, respectively.
Migraine recurred during the first week after childbirth in 34 per cent of the women and during the first month in 55 per cent. Certain risk factors for lack of improvement of migraine during pregnancy were identified: the presence of menstrually-related migraine before pregnancy was associated with a lack of headache improvement in the first and third trimesters, while second-trimester hyperemesis and a pathological pregnancy course were associated with a lack of headache improvement in the second trimester. Breast-feeding seemed to protect from recurrence during postpartum.
So what is the simplest and safest advice for Jill?
Common triggers of migraine include certain foods (chocolate, cheese, fried food, red wine), emotions (tension, anger, depression), change of routine (poor sleep, excitement, holiday and travel), missing meals, bright lights, flickering lights, noise and strong smells. So simple lifestyle changes may well help. Also Jill should be advised to take her paracetamol at the first signs of the migraine and not wait until it becomes unbearable.
Analgesics often work better when taken early. Having a nap in a dark quiet room may also help. Some migraine sufferers find a tight headband lessens throbbing headaches – this may work by decreasing scalp blood flow.
What about some of the more commonly used medications – how safe are they in pregnancy?
Let's consider the medications most commonly used – analgesics, abortive agents (serotonin agonists or ergot) and migraine prophylaxis.
Paracetamol has been well-studied in pregnancy and does not appear to increase the risk for birth defects or other adverse outcomes. But maternal aspirin use during the third trimester has been associated with adverse effects, including uterine contraction inhibition, increased maternal and newborn bleeding and premature narrowing of the fetal ductus arterious. Therefore aspirin-containing medications such as MigraMax, as well as NSAIDs in general, should be avoided, especially during the third trimester.
Codeine is present in many migraine treatments. Some case control studies and case reports have suggested defects such as cardiac and respiratory system defects, inguinal hernia, clefting and dislocated hips may occur more frequently in babies born to mothers who consumed codeine during pregnancy.
However, the Collaborative Perinatal Project and Michigan Medicaid study examined exposure to codeine in 565 and 7,640 exposed pregnancies, respectively, and did not find an increased risk of birth defects. It is unlikely therefore that codeine significantly increases the risk for malformations.
So prescribing co-codamol for a woman with severe migraine in the first and second trimesters is probably safe. Codeine should be avoided in the third trimester as it has been associated with an increased risk for transient neonatal withdrawal symptoms.
Ergot derivatives (Cafergot amd Migril) contain ergotamine and caffeine. Because of the reported increased risk for birth defects and the theoretical vasoconstrictive and labour-inducing properties, ergotamine and its derivatives should be avoided during pregnancy.
Serotonin receptor agonists, such as sumatriptan, have not been associated with an increased risk for birth defects. The BNF recommends that these medications be used with caution in pregnancy and breast-feeding. It does not list them as a contraindication.
For migraine prophylaxis you have to consider the severity and frequency of the headaches compared with the risks to the fetus. Propranolol and pizotifen can be used with caution so it is best to start at lower doses and slowly build up.
If Jill is reluctant to try anything stronger than paracetamol can we recommend anything else?
Several complementary therapies can certainly help. Acupuncture is particularly effective against migraine. Treatment usually involves three-four treatments initially followed by regular 'top-up' sessions every four-six weeks.
Muscle tension around the head and neck can lead to migraines. Relaxation, meditation, stress counselling and head massage may help significantly.
Facial callisthenic exercises will help relax the muscles and prevent tension (raise eyebrows together, then separately, make faces, yawn). Sleeping on the side or back puts less strain on neck muscles.
Avoiding chewing gum can also help – the repetitive action can cause muscle tension. Lastly Jill should be encouraged to join a migraine association.
Tanvir Jamil is a
GP in Burnham, Buckinghamshire, and is on a year's sabbatical in Canada
Migraine Action Association
Tel: 01536 461333
Fax: 01536 461444