By Susan Rubin, M.D.
Director of the Women’s Neurology Center at Glenbrook Hospital, Glenview, Illinois
THE CASE
Thirty-six year old Julia wants to have a child, but she has one problem. She has a long history of chronic daily headaches and migraines that she is barely able to control with multiple preventive and abortive medications—medications she worries might not be safe for a developing fetus. She wonders which medications are safe during pregnancy and how she can wean off the ones that aren’t. She also wonders if there are treatments she can use for headache control while she tries to get pregnant and during pregnancy.
DISCUSSION
This case raises two questions. First, which medications are safe during pregnancy and how do you discontinue the ones that aren’t? Second, what alternatives are available to treat headaches in women planning pregnancy?
Unfortunately, there are currently no medications that are definitively safe during pregnancy. The goal is to limit exposure to any unnecessary medications whenever possible. It is important to schedule an appointment with a healthcare provider before getting pregnant, or as soon as a woman knows she is pregnant, to review medication use. Many medications are not safe during pregnancy, while some are safe during one stage of pregnancy but not another.
All medications are assigned a pregnancy category (A through D and X) by the US Food and Drug Administration (FDA). The categories reflect what is known about the risks to a fetus if taken during pregnancy, with A being the safest and X having a high risk of causing birth defects. Most medications used to prevent or relieve migraines are Category C, which means either no adequate studies have been done (animal or human) or there were adverse effects in animal studies, but no available human data.
Some medications used for migraines, in particular beta blockers, antinausea medications and narcotic or Tylenol-based pain relievers, are Category B, which indicates that animal studies show no fetal risks, but no human studies have been done; or well-controlled human studies have not confirmed an expected risk. These medications are thought to be safer during pregnancy and might be used if necessary. Valproic acid, which is FDA-approved for migraine prevention, is a Category D, indicating that there is a known fetal risk—the benefit, then, must clearly outweigh the risk in order to justify its use during pregnancy. By reviewing the medication pregnancy classification, then, we can determine which medications are safe and which should be discontinued prior to pregnancy.
Discontinuing medications should be done gradually, over multiple months, to allow the body to adjust to lower doses and to introduce alternative treatments that can help prevent an increase in headache frequency. These include lifestyle adjustments and good health practices such as healthy eating, good sleep hygiene (adequate sleep and regular waking and bedtimes), and regular exercise. Alternative treatments like biofeedback, physical and massage therapy, or vitamins and minerals like B2 and magnesium are safe and effective ways to maintain headache control.
If patients cannot completely wean off potentially harmful medications, the substitution of Category B or C medications that have shown safety in early pregnancy (such as fluoxetine or metoprolol) might be an option with the goal of weaning off the drug before the third trimester. Prior to pregnancy, occipital nerve blocks or other local injections may help improve headache control, but long-acting medications like Botox® should be avoided since there is the risk of some systemic absorption.
Julia sought the advice of a genetics specialist who confirmed which of her medications had been associated with birth defects and which appeared to be safe. She weaned herself off her medications while she began biofeedback and an exercise routine. She also received occipital nerve blocks, which further facilitated her medication withdrawal. She is confident she has done everything she can to limit the risk of birth defects and is now ready to become pregnant.