Worsening Migraine in Pregnancy Is Linked to Adverse Outcomes

VALENCIA, SPAIN—Women who present with acute severe migraine during pregnancy are at increased risk for adverse pregnancy outcomes and should be seen in a high-risk pregnancy clinic, according to research presented at the International Headache Congress.

“We should not be seeing these patients in a regular [obstetrician’s or] generalist’s office because oftentimes we need input from neurology, and we need extra surveillance for both the fetus and the mother,” said Tracy B. Grossman, MD, an obstetrics and gynecology resident at Montefiore Medical Center in New York.

Dr. Grossman described a retrospective study of 90 consecutive pregnant patients who presented with acute severe migraine and obtained a neurology consultation at Montefiore Medical Center.

“These patients are different from most migraine patients because most migraine patients actually see improvement of symptoms during pregnancy. So, this is a special group of patients with worsening and refractory migraine,” she said.

Most of the women were in their third trimester. Diagnoses included migraine with aura (11.6%), migraine without aura (59.3%), and both (29.1%). A minority had chronic migraine (12.8%), and 31.4% presented in status migrainosus.

Forty-nine of the 90 patients (54%) experienced one or more adverse pregnancy outcomes. The population’s preterm delivery rate was 28%, which is nearly three times the national average of 11%, as reported by the March of Dimes. The population’s preeclampsia rate was 20.5%, compared with a national rate of 3% to 4%. The low-birth-weight rate of 19.2% was more than double the 8% national average. The rate of cesarean sections was 30.8%.

The study hypothesis was that women with migraine with aura would have higher rates of preeclampsia, preterm delivery, and low birth weight. Although studies of migraine in pregnancy have been few, some investigators have reported these associations. The current study did not find these associations, however, because most of the patients did not have aura, said Dr. Grossman.

“It can’t be purely an aura [or] vascular phenomenon that’s resulting in these adverse outcomes. These high rates of adverse pregnancy outcomes aren’t easily explainable. There’s something going on here that we haven’t teased out yet as to why these migraine patients are special,” she said.

Their risk of adverse pregnancy outcomes was not related to the headache medications that the patients took. Sixty-two patients received a combination of oral and IV therapy with acetaminophen, metoclopramide, and dihydroergotamine. In addition, 30% of patients briefly took barbiturates, and 30% received oxycodone or codeine. Although these drugs raise concerns during pregnancy, the investigators found no associated increase in adverse pregnancy outcomes among women who received them, compared with the women who did not receive those drugs or who did not receive any headache medications.

Dr. Grossman’s own therapeutic preference for patients with severe migraine during pregnancy is a peripheral nerve block with bupivacaine and lidocaine. “It works for the majority of people—we don’t quite know why—and it’s a local therapy that avoids fetal exposure to systemic medications,” she observed.

—Bruce Jancin

VALENCIA, SPAIN—Women who present with acute severe migraine during pregnancy are at increased risk for adverse pregnancy outcomes and should be seen in a high-risk pregnancy clinic, according to research presented at the International Headache Congress.

“We should not be seeing these patients in a regular [obstetrician’s or] generalist’s office because oftentimes we need input from neurology, and we need extra surveillance for both the fetus and the mother,” said Tracy B. Grossman, MD, an obstetrics and gynecology resident at Montefiore Medical Center in New York.

Dr. Grossman described a retrospective study of 90 consecutive pregnant patients who presented with acute severe migraine and obtained a neurology consultation at Montefiore Medical Center.

“These patients are different from most migraine patients because most migraine patients actually see improvement of symptoms during pregnancy. So, this is a special group of patients with worsening and refractory migraine,” she said.

Most of the women were in their third trimester. Diagnoses included migraine with aura (11.6%), migraine without aura (59.3%), and both (29.1%). A minority had chronic migraine (12.8%), and 31.4% presented in status migrainosus.

Forty-nine of the 90 patients (54%) experienced one or more adverse pregnancy outcomes. The population’s preterm delivery rate was 28%, which is nearly three times the national average of 11%, as reported by the March of Dimes. The population’s preeclampsia rate was 20.5%, compared with a national rate of 3% to 4%. The low-birth-weight rate of 19.2% was more than double the 8% national average. The rate of cesarean sections was 30.8%.

The study hypothesis was that women with migraine with aura would have higher rates of preeclampsia, preterm delivery, and low birth weight. Although studies of migraine in pregnancy have been few, some investigators have reported these associations. The current study did not find these associations, however, because most of the patients did not have aura, said Dr. Grossman.

“It can’t be purely an aura [or] vascular phenomenon that’s resulting in these adverse outcomes. These high rates of adverse pregnancy outcomes aren’t easily explainable. There’s something going on here that we haven’t teased out yet as to why these migraine patients are special,” she said.

Their risk of adverse pregnancy outcomes was not related to the headache medications that the patients took. Sixty-two patients received a combination of oral and IV therapy with acetaminophen, metoclopramide, and dihydroergotamine. In addition, 30% of patients briefly took barbiturates, and 30% received oxycodone or codeine. Although these drugs raise concerns during pregnancy, the investigators found no associated increase in adverse pregnancy outcomes among women who received them, compared with the women who did not receive those drugs or who did not receive any headache medications.

Dr. Grossman’s own therapeutic preference for patients with severe migraine during pregnancy is a peripheral nerve block with bupivacaine and lidocaine. “It works for the majority of people—we don’t quite know why—and it’s a local therapy that avoids fetal exposure to systemic medications,” she observed.

—Bruce Jancin

VALENCIA, SPAIN—Women who present with acute severe migraine during pregnancy are at increased risk for adverse pregnancy outcomes and should be seen in a high-risk pregnancy clinic, according to research presented at the International Headache Congress.

“We should not be seeing these patients in a regular [obstetrician’s or] generalist’s office because oftentimes we need input from neurology, and we need extra surveillance for both the fetus and the mother,” said Tracy B. Grossman, MD, an obstetrics and gynecology resident at Montefiore Medical Center in New York.

Dr. Grossman described a retrospective study of 90 consecutive pregnant patients who presented with acute severe migraine and obtained a neurology consultation at Montefiore Medical Center.

“These patients are different from most migraine patients because most migraine patients actually see improvement of symptoms during pregnancy. So, this is a special group of patients with worsening and refractory migraine,” she said.

Most of the women were in their third trimester. Diagnoses included migraine with aura (11.6%), migraine without aura (59.3%), and both (29.1%). A minority had chronic migraine (12.8%), and 31.4% presented in status migrainosus.

Forty-nine of the 90 patients (54%) experienced one or more adverse pregnancy outcomes. The population’s preterm delivery rate was 28%, which is nearly three times the national average of 11%, as reported by the March of Dimes. The population’s preeclampsia rate was 20.5%, compared with a national rate of 3% to 4%. The low-birth-weight rate of 19.2% was more than double the 8% national average. The rate of cesarean sections was 30.8%.

The study hypothesis was that women with migraine with aura would have higher rates of preeclampsia, preterm delivery, and low birth weight. Although studies of migraine in pregnancy have been few, some investigators have reported these associations. The current study did not find these associations, however, because most of the patients did not have aura, said Dr. Grossman.

“It can’t be purely an aura [or] vascular phenomenon that’s resulting in these adverse outcomes. These high rates of adverse pregnancy outcomes aren’t easily explainable. There’s something going on here that we haven’t teased out yet as to why these migraine patients are special,” she said.

Their risk of adverse pregnancy outcomes was not related to the headache medications that the patients took. Sixty-two patients received a combination of oral and IV therapy with acetaminophen, metoclopramide, and dihydroergotamine. In addition, 30% of patients briefly took barbiturates, and 30% received oxycodone or codeine. Although these drugs raise concerns during pregnancy, the investigators found no associated increase in adverse pregnancy outcomes among women who received them, compared with the women who did not receive those drugs or who did not receive any headache medications.

Dr. Grossman’s own therapeutic preference for patients with severe migraine during pregnancy is a peripheral nerve block with bupivacaine and lidocaine. “It works for the majority of people—we don’t quite know why—and it’s a local therapy that avoids fetal exposure to systemic medications,” she observed.

—Bruce Jancin