Women With Migraine 'High-Risk' Patients During Pregnancy

Pregnant women with migraine are at increased risk for more obstetric and postpartum complications and should be considered "high risk," new research suggests.

Although pregnancy is generally considered a "safe period" for women with migraine, "we actually found they have more diabetes, more hypertension, more blood clots, more complications during their delivery, and more postpartum complications," study investigator Nirit Lev, MD, PhD, head, Department of Neurology, Meir Medical Center, Kfar Saba Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel, told Medscape Medical News.

The results highlight the need for clinicians "to take people with migraines seriously" and reinforce the idea that migraine is not "just a headache," said Lev.

Pregnant women with migraine should be considered high risk and have specialized neurologic follow-up during pregnancy and the postpartum period, she added.

The findings were presented at the virtual Congress of the European Academy of Neurology (EAN) 2021.

Prevalent, Disabling

Migraine is one of the most prevalent and disabling neurologic disorders. Such disorders are major causes of death and disability.

In childhood, there's no difference between genders in migraine prevalence, but after puberty, migraine is about three times more common in women than men. Fluctuating levels of estrogen and progesterone likely explain these differences, said Lev.

The prevalence of migraine among females peaks during their reproductive years. Most women migraine patients report an improvement in headache symptoms during pregnancy, with some experiencing a "complete remission." However, a minority report worsening of migraine when expecting a child, said Lev.

Some patients have their first aura ― a transient neurologic deficit that precedes the headache ― during pregnancy. The most common migraine aura is visual, a problem with the visual field that can affect motor and sensory functioning, said Lev.

Managing migraine during pregnancy is "very complicated," said Lev. She said the first-line treatment is paracetamol (acetaminophen) and stressed that taking opioids should be avoided.

For the study, the researchers retrospectively reviewed pregnancy and delivery records from a database of Clalit Medical Services, which has more than 4.5 million members and is the largest such database in Israel.

They collected demographic data and information on mode of delivery, medical and obstetric complications, hospitalizations, emergency department visits, use of medications, laboratory reports, and medical consultations.

The study included 145,102 women who gave birth from 2014 to 2020.

Of these, 10,646 had migraine without aura, and 1576 had migraine with aura. The migraine diagnoses, which were based on International Headache Society criteria and diagnostic codes, were made prior to pregnancy.

Lev noted that the number of patients with migraine is likely an underestimation because migraine is "not always diagnosed."

Results showed that the risk for obstetric complications was higher among pregnant women with migraine, especially those with aura, in comparison with women without migraine.

About 6.9% of patients with migraine without aura were admitted to high-risk hospital departments, compared to 6% of pregnant control patients who did not have migraine (P < .0001). For patients with migriane with aura, the risk for admissions was even higher (8.7%; P < .0001 vs control patients and P < .03 vs patients with migraine without aura) and was "very highly statistically significant," said Lev.

Pregnant women with migraine were at significantly increased risk for gestational diabetes, hyperlipidemia, and being diagnosed with a psychiatric disorder (all P < .0001). These women were also more likely to experience preeclampsia and blood clots (P < .0001).

Unexpected Finding

The finding that the risk for diabetes was higher was "unexpected," inasmuch as older women with migraine are typically at increased risk for metabolic syndrome and higher body mass index, said Lev.

Migraine patients had significantly more consultations with family physicians, gynecologists, and neurologists (P < .0001). In addition, they were more likely to utilize emergency services; take more medications, mostly analgesics; and undergo more laboratory studies and brain imaging.

Those with aura had significantly more specialist consultations and took more medications compared to migraine patients without aura.

There was a statistically significant increase in the use of epidural anesthesia for migraine patients (40.5% of women without migraine; 45.7% of those with migraine accompanied by aura; and 47.5% of migraine patients with aura).

This was an "interesting" finding, said Lev. "We didn't know what to expect; people with migraine are used to pain, so the question was, will they tolerate pain better or be more afraid of pain?"

Women with migraine also experienced more assisted deliveries with increased use of vacuums and forceps.

During the 3-month postpartum period, women with migraine sought more medical consultations and used more medications compared to control patients. They also underwent more lab examinations and more brain imaging during this period.

Lev noted that some of these evaluations may have been postponed because of the pregnancy.

Women with migraine also had a greater risk for postpartum depression, which Lev found "concerning." She noted that depression is often underreported but is treatable.

Women with migraine should be monitored for depression post partum, she said.

It's unclear which factors contribute to the increased risk for pregnancy complications in women with migraine. Lev said she doesn't believe it's drug related.

"Although they're taking more medications than people who don't have migraine, we still are giving very low doses and only safe medicines, so I don't think these increased risks are side effects," she said.

She noted that women with migraine have more cardiovascular complications, including stroke and myocardial infarction, although these generally affect older patients.

Lev also noted that pain, especially chronic pain, can cause depression. "We know that people with migraine have more depression and anxiety, so maybe that also affects them during their pregnancy and after," she said.

She suggested that pregnant women with migraine be considered high risk and be managed via specialized clinics.

Room for Improvement

Commenting on the research for Medscape Medical News, Lauren Doyle Strauss, DO, associate professor of neurology, Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina, who has written about the management of migraine during pregnancy, said studies such as this help raise awareness about pregnancy risks in migraine patients.

Strauss did not attend the live presentation but is aware of the findings.

The increased use of epidurals during delivery among migraine patients in the study makes some sense, said Strauss. "It kind of shows a comfort level with medicines."

She expressed concern that such research may be "skewed" because it includes patients with more severe migraine. If less severe cases were included in this research, "maybe there would still be higher risks, but not as high as what we have been finding in some of our studies," she said.

Strauss said she feels the medical community should do a better job of identifying and diagnosing migraine. She said would like to see migraine screening become a routine part of obstetric/gynecologic care.

Doctors should counsel migraine patients who wish to become pregnant about potential risks, said Strauss.

"We need to be up front in telling them when to seek care and when to report symptoms and not to wait for it to become super severe," she said.

She also believes doctors should be "proactive" in helping patients develop a treatment plan before becoming pregnant, because the limited pain control options available for pregnant patients can take time to have an effect.

Also commenting for Medscape Medical News, Nina Riggins, MD, PhD, clinical associate professor of neurology at the University of California, San Francisco, said the study raises "important questions" and has "important aims."

She believes the study reinforces the importance of collaboration between experts in primary care, obstetrics/gynecology, and neurology.

However, she was surprised at some of the investigator's assertions that there are no differences in migraine among prepubertal children and that the course of migraine for men is stable throughout their life span.

"There is literature that supports the view that the prevalence in boys is higher in prepuberty, and studies do show that migraine prevalence decreases in older adults ― men and women," she said.

There is still not enough evidence to determine that antiemetics and triptans are safe during pregnancy or that pregnant women with migraine should be taking acetylsalicylic acid, said Riggins.

The investigators, Strauss, and Riggins have disclosed no relevant financial relationships.

Congress of the European Academy of Neurology (EAN) 2021: Abstract OPR-066. Presented June 20, 2021.

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