Talking to Your OB About Migraine: Building a Pregnancy Migraine Plan

Obstetricians and midwives are experts in pregnancy and childbirth. They are not typically headache specialists. This means that the management of migraine during pregnancy falls into a clinical gap between two areas of expertise, and navigating that gap effectively requires patients to be active participants in coordinating their care.

Many women with migraine do not discuss the condition with their OB provider proactively, either because they assume migraine will improve during pregnancy, because they believe there is nothing that can be done safely, or because they do not want to add complexity to prenatal appointments that are already covering many other topics. Each of these assumptions has some truth to it but also significant limitations that can result in inadequate preparation and care.

When to Start the Conversation

The ideal time to discuss migraine with an OB provider is before pregnancy, during preconception counseling. This creates the opportunity to review current migraine medications for pregnancy safety, to transition off teratogenic medications before conception, to discuss what to expect during pregnancy regarding migraine patterns, and to develop a plan for management before the first trimester.

For women who are already pregnant when migraine becomes a management issue, the conversation should happen at the earliest opportunity. First trimester appointments, when the woman is establishing care with the OB provider, are an appropriate time to raise migraine as a condition that needs to be addressed in the context of the pregnancy.

What to Tell the OB Provider

The OB provider needs specific information to manage migraine appropriately in the context of pregnancy. This includes the confirmed migraine diagnosis, the typical frequency and severity of attacks, the medications currently being used for both acute and preventive treatment, and any prior treatment history relevant to pregnancy management.

A summary of current medications with their doses is essential because the OB provider will need to assess each one for pregnancy safety and may need to recommend alternatives. Women who are taking valproate or topiramate, which carry significant teratogenic risks, need urgent discussion with their neurologist and OB provider to transition off these medications before or as early as possible in pregnancy.

Questions to Ask the OB Provider

Several questions are worth raising with the OB provider. Which of my current migraine medications are safe to continue during pregnancy? What acute medications are available if my migraines are severe and not responding to acetaminophen? At what point should I call the office versus going to an emergency room for a migraine attack during pregnancy? Are there any warning signs in my headaches during pregnancy that should prompt urgent evaluation?

The question about warning signs is particularly important because new or different headache during pregnancy can sometimes reflect complications including preeclampsia or cerebral venous sinus thrombosis that require urgent evaluation and are distinct from primary migraine.

Coordinating With a Neurologist or Headache Specialist

For women with frequent or severe migraine, coordinating care between the OB provider and a neurologist or headache specialist produces the best outcomes. The neurologist brings expertise in migraine pathophysiology and treatment options. The OB provider brings expertise in pregnancy physiology and fetal safety. Neither alone has the complete picture.

If a woman does not have an established relationship with a neurologist before pregnancy, the first trimester is a reasonable time to establish one if migraine is frequent or severe. The American Migraine Foundation provider directory can help identify headache specialists who have experience with pregnancy-related migraine management.

Building the Plan

A pregnancy migraine plan should include the acute medications available if migraine occurs, the threshold for calling the OB provider versus managing at home, the threshold for emergency evaluation, the non-pharmacological strategies to try first, and the contact information for both the OB provider and the neurologist.

Having this plan established before it is needed, rather than improvising during a severe attack, reduces the risk of decisions made under pain and distress and improves the likelihood of appropriate management throughout the pregnancy.