A 25-year-old primigravida at the 32nd week of pregnancy comes to the physician with increasing headaches. She describes the headaches as severe in intensity, unilateral, throbbing, and associated with light sensitivity and nausea. They currently occur once or twice a week. She has had similar headaches for the last several years that usually improve with ibuprofen and bed rest. However, she does not want to take any unsafe drugs. The patient has tried massage, relaxation, and techniques to improve her sleep without significant improvement. She has no other medical problems. Her current medications include an oral multivitamin.
Vital signs and examination are within normal limits.
Which of the following is the most appropriate course of action?

Question

A 25-year-old primigravida at the 32nd week of pregnancy comes to the physician with increasing headaches.  She describes the headaches as severe in intensity, unilateral, throbbing, and associated with light sensitivity and nausea.  They currently occur once or twice a week.  She has had similar headaches for the last several years that usually improve with ibuprofen and bed rest.  However, she does not want to take any unsafe drugs.  The patient has tried massage, relaxation, and techniques to improve her sleep without significant improvement.  She has no other medical problems.  Her current medications include an oral multivitamin.
Vital signs and examination are within normal limits.
Which of the following is the most appropriate course of action?

Quizplus · Accepted Answer

This patient has typical migraine headaches, with management complicated by pregnancy. Patients with severe symptoms or who are refractory to non-drug therapies (eg, hydration, massage, ice packs) should receive medications with minimal fetal risk. Acetaminophen is preferred due to its low risk of adverse events. Patients not responding to acetaminophen alone may benefit from adding an antiemetic (eg, metoclopramide), codeine, or caffeine/butalbital. However, butalbital and codeine should be used sparingly to avoid medication overuse headache. Nonsteroidal anti-inflammatory drugs such as naproxen can be used as a 2nd option in patients not responding to acetaminophen but should be used only in brief courses; they are associated with fetal toxicity in the 1st and 3rd trimesters (Choice C). Stronger opioids (eg, oxycodone) are 3rd-line therapy but can be habit-forming and possibly worsen nausea/vomiting and constipation during pregnancy. Parenteral antiemetics can also be considered acutely and can be used as monotherapy for migraines. (Choice B) Ergotamine is contraindicated during pregnancy due to the risk of inducing hypertonic uterine contractions and vasoconstriction, which can lead to adverse fetal effects. (Choice D) The "triptans" (eg, sumatriptan) can be considered in patients who are refractory to other therapies. However, some studies have shown an increased risk of vasoconstriction of uteroplacental vessels, increased uterotonic activity, preterm delivery, and low birth weight. (Choice E) Topiramate has been associated with adverse events and is contraindicated during pregnancy. Beta blockers (eg, propranolol) are generally preferred for patients requiring prophylaxis. Educational objective: Acetaminophen is the preferred medication for migraines during pregnancy due to its low risk of adverse events. Other options in patients not responding to acetaminophen include nonsteroidal anti-inflammatory drugs (2nd trimester), opioids, and antiemetics. __________ References: Migraine during pregnancy: options for therapy. (http://www.ncbi.nlm.nih.gov/pubmed/15962998) Treatment of acute migraine headache. (http://www.ncbi.nlm.nih.gov/pubmed/21302868)

A 25-Year-Old Primigravida at the 32nd Week of Pregnancy Comes