For women with high frequency of migraine or significant disability due to migraine, the risk of pharmacologic agents needs to be weighed against the health consequences of untreated migraine, which can negatively affect both the mother and fetus. 11,12 Although these approaches are viable first-line treatment options for some pregnant women or individuals considering pregnancy, they may not be sufficient for others. These approaches include relaxation therapy, biofeedback, and behavioral sleep modification, the latter of which may revert chronic migraines to episodic. It is best to start nonpharmacologic behavioral changes known to decrease frequency and severity of migraines before pregnancy to make them learned behaviors. The lack of a standardized risk assessment is both a strength and weakness of this update, requiring individual review of each medication for a specific individual. With the new labeling system, clinicians cannot rely on a predetermined risk category, but need to review the current data and make an informed decision on a case-by-case basis. The new system eliminates what some considered an overly simplistic pregnancy risk system that did not detail current data available on each pharmacologic agent. This summary includes any human, animal, and pharmacologic risk data available. 9 In 2015, the Food and Drug Administration (FDA) implemented the Pregnancy and Lactation Labeling Rule, removing previously used letter codes for pregnancy risk stratification in exchange for a narrative summary. Risk stratification of pharmacologic intervention is important, because 70% of pregnant women report taking at least 1 prescription medicine. 7 A more recent prospective observational study, however, showed no teratogenic effect of migraine itself. A retrospective study showed that women treated for acute migraine had higher rates of preterm delivery, preeclampsia, and low birthweight. Migraine itself may be a potential teratogen. 6 Regardless of whether women’s migraines were menstrual or nonmenstrual, headache intensity decreased during the second half of pregnancy as did frequency of analgesic use. 5 In a study of pregnant women with menstrual migraine, participants reported increased headache intensity but not frequency early in pregnancy (week 7), compared with pregnant women whose migraines were not menstrual. 5 Migraine with aura is less likely to improve or remit compared with migraine without aura. 4 The number of women with complete remission in the first trimester is low (10.6%) however, the rate of complete remission increases significantly as pregnancy progresses (78.7% in third trimester). 3 Almost half of women with migraine have improvment during the first trimester (46.8%), and this improvement increases substantially in the second (83%) and third (87.2%) trimesters. 2,3 A link between migraine and the female sex hormones, estrogen and progesterone, is seen in menstrual migraine and migraine in pregnancy. Migraine headaches often improve during pregnancy, but have also been to known to worsen or start during pregnancy. During this visit, an individualized migraine treatment plan for use in pregnancy can be created, which can ease stress related to treatment. For those planning pregnancy, a preconception office visit can ease concerns about medication use for migraine treatment during pregnancy. Migraine has a higher prevalence in women, especially during reproductive years, 1 presenting a clinical challenge of balancing the risks and benefits of migraine treatment against potential risks to fertility and offspring for women with childbearing potential.
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