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Migraine and Pregnancy
The good news about migraine and pregnancy is that in general, migraines get better during pregnancy. If you are having migraines for the first time during pregnancy, then please see a neurologist immediately. This article is not for you. This article is for women who have migraines and are planning to become pregnant or are pregnant and need to know how to treat their migraines before, during, and after pregnancy while breastfeeding. It is very difficulty to find neurologist to actually treat migraines while pregnant. Many physicians and patients have the idea that since migraine is benign, it is better to let the pregnant patient suffer rather than treat. Dr. Loftus does not agree with this determination as being bedridden with headaches is probably not completely benign for the fetus either. For those in the Houston area, this article will explain the treatments that are available to Dr. Loftus' patients. For those not in the Houston area, Dr. Loftus does offer virtual visits. Dr. Loftus can discuss your treatment options that are safe before and during pregnancy. Some of these are things you would do at home. A few of them do require in office treatment but if your current neurologist has an infusion suite, he may be able to use your physician at home to do some of the treatments.
It is generally best to work with the neurologist prior to pregnancy. In fact, given the number of potential devices and treatments to try, have a year or two can really be very helpful. As a general rule, when choosing oral preventatives, Dr. Loftus will try and use the ones that are safe for pregnancy in young women even if they are not trying to become pregnant. It is likely that any woman who needs prevention before they want to get pregnant will have the need for prevention when they are trying to get pregnant. Therefore, all things being equal, you might as well try those things that could be used during pregnancy before trying those things that are to be avoided during pregnant. Once a patient decides she is a year or two away from trying to get pregnant, then it is time to begin to try those things that will be used going into pregnancy. The first goal is to avoid all things that directly exposes the fetus to any foreign chemicals. Because of this, we generally start with the office procedures and devices. There are pages about these devices and procedures but this page will discuss how they are utilized around pregnancy.
Cefaly
While cefaly is unlikely to solve all problems related to pregnancy and migraines, it is a device that every women planning pregnancy should try. There are actually 3 devices and 2 modes under the cefaly brand. The two modes are acute and prevention. Because it works by stimulating part of the trigeminal nerve, the acute mode is an excellent way to treat all headaches that occur during pregnancy. Headache treatment during the second trimester is particularly problematic while triptans may be used during the first trimester. The device has a prevention mode as well and if there is plenty of time for experimentation, then this should also be tested. While the cost of the device is $500, you then own it. Monthy cost for pads for the prevention mode will generally cost less than $25 and if you only run the device for acute treatments, the monthly cost will be even less. At the time this was written, there was a 60 day money back offer so if it does not work you can return it and only be out the cost of the pads.ou can learn more about cefaly here.
Pericranial Nerve Blocks (PNB)
When it comes to looking at cost per month of effective treatment for non-oral solutions, nothing is cheaper than the combined trigemial and occipital nerve blocks. Dr. Loftus uses a procedure slightly modified from Dr. Kaneicki. The cost is $300 and if it works, it lasts for 12 weeks 75% of the time. Except during the first trimester, bupivacaine 0.25% or 0.5% is used. During the first trimester, lidocaine 2% is used. It probably does not matter. The overall dose is so low that the fetus is unlikely to see either medication but lidocaine is category B (safe for pregnancy) and bupivacaine is category C (safety is unknown). If lidocaine does not work as well as bupivacaine, the blocks can always be repeated using bupivacaine. One of the best things about this therapy is that it can be used before and during pregnancy as well as during breast feeding. You can learn more about PNB here.
Sphenopalatine Ganglion (SPG) block using the Allevio® device
There are many ways to attempt to do SPG block. The device used by Dr. Loftus is the Allevio® device and this is functionally the same as the Sphenocath® device but is very different from the Tx360® device. Bingalah M, et. al. published an open label case series that showed a 78% headache free rate at 2 hours with about 90% of that group staying headache free for 24 hours. While the initial response is typically excellent, there is about 30% of patients that go 2-3 weeks without additional headaches. When repeated, most patients spread out and seem to average 2-3 months. At a cost of $250 per treatment, this approaches the cost benefit of the nerve blocks. Side effects are few with 1-2% incidence of 4-8 hours of nausea with vomiting in non-pregnant patients and a somewhat higher incidence of nausea and vomiting for 4-8 hours in pregnant women. Scopolamine patch seems to be the best treatment option but this is category C for pregnancy. On the other hand, metoclopramide and ondansetron do not seem to work at all in Dr. Loftus' experience. For those with acute severe migraines where cefaly does not work, it is best to determine how long the procedure seems to work for prevention prior to pregnancy so the patient can be placed on a schedule to repeat the blocks prior to them wearing off. The best part of prevention with SPG block is that it tends to either be virtually 100% or not work at all. When it works, it is amazing, but unfortunately it does not work as a preventative for most patients. It does however, work as a great rescue with the only limitation being difficulty placing the block in some patients due to their nasal anatomy and the need to lie back and still which is not possible for those patients that vomit frequently with their migraines. You can learn more about SPG block here.
Gammacore®
The Gammacore® device can be used by patients to treat acute migraines. I suspect it works a higher percentage of time then the cefaly device but at a price of about $500 per month, it is of course more expensive. Insurance coverage has beem problematic but is getting better. Because there is some skill in learning to use this device as well as apprehension to shock one self on the neck, it is best to experiment with it before you are pregnant. 50% of patients will get headache relief when using the device (no headache or mild headache when starting with moderate or worse headache). When using gammacore for prevention of migraine, it improves over time. Therefore, having a lot of lead in months is very helpful. You can learn more about gammacore here.
Intermittent IV magnesium
Many headache specialist utilize IV magnesium as an adjunct for acute headache as well as a migraine preventative. Well controlled data is limited. There are two studies indicating IV magnesium being useful for acute headache. There is an additional study indicating it is not helpful. There are no studies for prevention. Dr. Loftus' clinical opinion is that it is indeed very helpful for migraine prevention with an estimated 70% of patients doing 50% better after 4 weekly treatments. Hopefully, we will have more controlled studies in the near future. While there is limited data regarding the safety of intermittent IV magnesium in early pregnancy, there is a large volume of data regarding the safety of IV magnesium in later pregnancy. While high doses of IV magnesium for several days may have some negative effects on the fetus, the total exposure for the prevention of migraine during the third trimester is less than 2 hours of exposure of IV magnesium when it is used to treat eclampsia.
Botox®
Although there is some debate as to the best way to utilize Botox®, Dr. Loftus always begins his Botox® patients with the FDA approved 31 injection paradigm. The treatment algorithm is repeated every 84 days. In general, one does two cycles in order to determine if there appears to be an adequate response to continue to use this treatment. The good news about Botox® for chronic migraine prevention, is that all of the side effects wear off. The medication has been in use for more than 25 years and so the long term safety is well established. In the short term, the most common side effect of this treatment is transient weakness or pain in the neck. Prior to pregnancy, Botox® should be completely safe. Once pregnant, Dr. Loftus has never used this treatment. When used, the hope is once the woman is pregnant, then the migraines will naturally get better and additional prevention will no longer me needed. When trying to get pregnant, Dr. Loftus is starting to use Zytaze® routinely. Zytaze is designed to increase the level of zinc in the tissues and zinc is a necessary cofactor for all botulinum toxins to work. Although not studied for wearing off during migraine, in well controlled studies of other diseases, it lengthens the effectiveness of Botox® by 30%. Dr. Loftus does not use it routinely for patients not trying to get pregnant as it may increase the risk of neck weakness.
As the cost of Botox is about $500 per month, patients generally have to fail 2 or 3 prior treatments from different classes to get insurance coverage. It is generally covered only for chronic migraine and not for migraines with less than 15 headache days per month. This does not mean it will not work for those with 10 or even 5 headache days per month but the current paradigm used for chronic migraine has not been tested in those patients with episodic migraines. You can learn more about botox for Migraine here.You can learn more about how Botox works here.