ARTIGO COMENTADO
Synopsis on the paper "Acute migraine in pregnancy:
Therapeutic opportunities"
Sinopse do artigo “Migrânea aguda na gravidez: oportunidades
terapêuticas”
Eliana Meire Melhado
Doutora e Mestre em Ciências Médicas, Docente de Neurologia da Fundação Padre Albino
Faculdade de Medicina de Catanduva, Catanduva, SP, Brazil
Melhado EM. Synopsis on the paper "Acute migraine in pregnancy: Therapeutic opportunities"
Headache Medicine. 2016;7(3):71-3
ABSTRACT
Acute migraine is a debilitating pain crisis for which there
are several therapeutic options, although no single universally
effective prescription. When the migraine attack occurs in
pregnant women, the pharmacological treatment options are
very limited and a complex situation arises, in which to do or
not to do have potential implications. The fear of possible
damage to the fetus by the mother or the physician and the
effect of recurrent and severe pain on the pregnant woman
do not have a unidirectional response. For most drugs, the
real risk potential in pregnancy has not been established,
and suffering from chronic or recurrent pain also has potential
adverse effects on pregnancy. This often leads to inaction or
to the prescription of medication that is not necessarily useful.
Pain should be treated effectively in all circumstances and
pregnancy is no exception. This paper reviews the available
options for the treatment of migraine attacks that may be
used in pregnant women.
RESUMEN
La migraña aguda es una crisis de dolor discapacitante para
la cual hay opciones terapéuticas pero no hay una única
prescripción eficaz universal. Cuando la crisis migrañosa se
produce en la mujer gestante son muy limitadas las opciones
terapéuticas farmacológicas y se plantea una compleja
situación en la que hacer o no hacer tienen su consecuencia
potencial. El temor al daño posible del feto por parte de la
madre o el médico y el efecto del dolor recurrente y severo
sobre la mujer embarazada no tiene una respuesta
unidireccional. En la mayoría de las medicaciones no está
establecido el riesgo potencial real en el embarazo y presentar
dolor crónico o recurrente tiene potenciales efectos nocivos
sobre el embarazo. Esto lleva muchas veces a la inacción o
SYNOPSIS
Buonanotte & Buonanotte started explaining
epidemiological aspects of migraine which affects on
average 11% to 14% of the adult population with a clear
female predominance. Headache improvement in 2
nd
and
3
rd
quarters of pregnancy is explained as related to women
with menstrual migraine before pregnancy. Even though,
some women migraines get worse during pregnancy, and
there are also complications such as preeclampsia, and
coagulation disorders.
The authors go into a delicate terrain: the neurophobia
in dealing with such women. This is a worldwide fact. The
prescripción de medicación que no necesariamente es útil.
El dolor debería tratarse eficazmente en todas las
circunstancias y esta no es la excepción. El presente trabajo
revisa las opciones de tratamiento de la crisis de migraña
con posibilidad de uso en la mujer embarazada.
Carlos Federico Buonanotte
a,b
; Maria Carla Buonanotte
c
a
Jefe Servicio Neurología, Sanatorio Allende Cerro,
Ciudad de Córdoba, Córdoba, Argentina
b
Jefe de Neurología, Hospital Nacional de Clínicas,
Córdoba, Argentina
c
Médica Neuróloga del Hospital Misericordia, Ciudad de
Córdoba, Córdoba, Argentina
Headache Medicine, v.7, n.3, p.71-73, Jul./Aug./Sep. 2016 71
scenario is more complicated when we consider the medical
act and the principle of beneficence of seeking the patient
well-being. There is the fear of medical legal consequences
in this case, by action or omission, which in practice leads
to considering that nothing could be pharmacologically
prescribed in this clinical context. There is also the
neurophobia by the fear of a secondary headache, added
to the logical fear of potential harm to the fetus. This is
associated with the existence of few safe drugs or medicines
which safety is known but studies cannot be performed,
thus tables are based on case reports.
Also, we must remember that 2 to 7% of migraines in
pregnancy are "de novo" and it is necessary to think of
secondary headaches, and that 35% of pregnant patients
in the doctor's waiting room have secondary headache.
Neuroimaging procedures are essential in the ancillary
investigation of those patients, and tomography and
magnetic resonance bring a minimal risk for both pregnant
women and fetus – as long as an intravenous contrast
enhancement is not used.
Secondary headaches to be considered in pregnancy
are hypertensive syndromes associated with pregnancy:
eclampsia and preeclampsia; posterior reversible
encephalopathy; hemolysis, increased liver enzymes, and
low platelets syndrome (HELLP); reversible cerebral
vasoconstriction syndrome; pituitary apoplexy; venous
thrombosis; brain hemorrhage: aneurysmal or AVM; artery
dissection; idiopathic intracranial hypertension; and
meningitis.
And then, the authors described the treatment of
migraines in pregnancy, giving emphasis to non-
pharmacological management. As for drugs, in acute pain
not every medication can be taken, and this should be
taken into account by migraineurs before becoming
pregnant.
Further, the paper elegantly addresses the need to
prevent migraine chronification, and discusses that among
the modifiable factors are overweight, snoring, sleep apnea
and insomnia, excessive consumption of caffeine, high
frequency of headaches, frequent use of analgesics, other
associated pains, neck trauma, emotional disturbances, and
social, labour or affective changes.
In this review, products such as riboflavin and
magnesium are emphasized with level of evidence B. Topical
products like capsaicin with mint prepared with ethyl alcohol
solution and topic acetaminophen are interesting to be
prescribed to pregnant women. And here this review brought
a novelty to the physicians who treat their pregnant
migraineur patients.
The paper defines teratogenicity which is the structural
or functional defect in organogenesis, involving from 3rd
to 8th gestational weeks. The teratogenic action produced
by medicines varies along the timeline related to the different
periods of susceptibility to the injury. The risk of teratogenicity
is not known in more than 90 % of the drugs approved by
the FDA.
The prescription should balance or consider aspects
which are very easy to be considered, even though difficult
to be performed or to act. This is because no controlled
studies are available, and the use of drugs would not be
recommended.
Considering the risk and benefit includes to evaluate
the gestational age and teratogenic risk at this stage, the
effectiveness of the medication, the risk categories of this
drug, and the will of the pregnant to use medication, to
decide to bear the pain (which I do not agree particularly),
to take the risk of the drug, to face the possibility of the
route of administration, and to take the effects of pain on
the body and on pregnancy, and the adverse effects of the
available medicines.
There is not enough evidence to recommend a
specific protocol in the treatment of acute migraine in
any given situation. This absence obliges the physician
to make a decision in each case where the indication
does not necessarily correlate to the prescription (in this
situation I name it as the 'art of medicine with little
evidence').
Yet, the paper describes the options in acute migraine
during pregnancy considering the principles of beneficence
and nonmaleficence.
Acetaminophen - no established risk, mothers often
use in pregnancy.
Anti-inflammatories - can be used diclofenac (50
mg), ibuprofen (400mg), naproxen (500 - 1,000 mg),
piroxicam and indomethacin, which are categorized as risk
B. Aspirin in doses of 900 - 1,000 mg shown efficacy in
relief from migraine, and the risk is C. Avoid in the first
quarter and in the woman who plans to become pregnant
due to the possibility to prevent ovulation, implantation of
the egg, or abortion. It is not recommended to use cyclo-
oxygenase-2 inhibitors.
Triptans - a recent meta-analysis study concluded
that the use of sumatriptan in pregnancy does not show
increased risk of prematurity or birth malformations, and
this sporadic use in pregnancy is acceptable because of
low-risk.
Opioids - the risk is C, as the triptans, but opioids are
associated with numerous complications in both the fetus
MELHADO EM
72 Headache Medicine, v.7, n.3, p.71-73, Jul./Aug./Sep. 2016
and the mother (physical dependence and withdrawal,
growth retardation, neonatal respiratory depression and
malformations). In general they are safe.
Magnesium - the infusion of 1 g of magnesium sulfate
demonstrated efficacy in controlling migrainous attacks.
Usage is safe in pregnancy and should not be administered
for more than 3 consecutive days since the prolonged use
may be associated with neonatal hypocalcemia and
osteopenia. For that reason it was reclassified as risk D.
It is interesting this reclassification of magnesium, and
this is another prominent aspect in this paper.
Antihistamines
Steroids - Steroids should not be prescribed more than
6 times. Dexamethasone has risk C and prednisone is B.
Dipyrone - It is as safe as the acetaminophen.
Antiemetics
Nerve Blocks
Acupuncture
The authors conclude by making the remark that to
decide a specific action on pregnant with migraine attacks
is a complex choice, in which multiple factors are present.
A strategy should be proposed for each particular case,
considering the opportunities, and evaluating the lower risk;
and the pain should always be treated.
The paper is very complete and brings some interesting
news. More and more papers of this nature with regard to
pregnant women are needed, since in this setting double-
blind randomized studies cannot be performed.
REFERENCES
Buonanotte CF, Buonanotte MC. Migraña aguda en embarazo:
oportunidades terapéuticas. Neurol Arg. 2016. http://
dx.doi.org/10.1016/j.neuarg.2016.05.004
SYNOPSIS ON THE PAPER "ACUTE MIGRAINE IN PREGNANCY: THERAPEUTIC OPPORTUNITIES"
Correspondence
Original Paper
C.F. Buonanotte
email: federicobuonanotte@gmail.com
Synopsis
E.M. Melhado
email: elianamelhado@hotmail.com
Recebido: June 20, 2016
Aceito: June 28, 2016
Headache Medicine, v.7, n.3, p.71-73, Jul./Aug./Sep. 2016 73
