Hi, I have had migraines for the past 15 years, and now I am pregnant and have daily headaches, both bordering on and becoming migraines. I am worried that medications could be harmful to my baby. How can I manage my headaches and be sure that my baby is safe? Also, are migraines hereditary – could my child inherit them?

Both tension type headaches and migraine headaches frequently increase during pregnancy. In particular, migraine headaches increase in frequency during the first trimester; however about 50% of women with migraine headaches will experience a reduction in their migraine headaches during the second and third trimesters. If an individual's headaches improve during her pregnancy, it is likely that they will resume their previous pattern or even worsen when that individual's menstrual cycle resumes after delivery. This improvement in headaches during the latter portion of pregnancy is likely correlated with hormonal changes.

There are some serious, albeit rare, causes of headache usually during the latter part of pregnancy through shortly after delivery. In particular, vascular malformations and aneurysms can bleed or rupture and blood clots in the veins of the brain can develop at that time. It is always reasonable to check with your physician or to go to the emergency room if you have a severe unexplained headache with or without other neurological symptoms during pregnancy or after delivery.

There is a lack of information about the effects of many headache medications in pregnant women. Ideally, women with headaches who desire to become pregnant should be encouraged to discontinue all medications prior to conception. Non medication treatments such as biofeedback and relaxation techniques may be helpful. Also identifying headache triggers, especially if they are dietary, may be helpful since most dietary triggers can be avoided. I had one pregnant patient who avoided all prepackaged foods to avoid preservatives. She even baked her own bread and made her own pasta. With these measures, she was able to reduce her headache frequency by 50%. The importance of obtaining adequate rest is of utmost importance as well. Reducing or avoiding stress can also impact on headache frequency. Caffeine should be avoided during the first trimester and perhaps even later during pregnancy. If your gynecologist allows minimal caffeine exposure, sometimes caffeine can treat an acute headache.

If medication is going to be used, the benefits must clearly outweigh the potential risks to the mother and the fetus. Whenever possible, medication treatment of headaches should be delayed until the second and third trimester, after the baby's organs have been formed. For mild to moderate headache in pregnancy, acetaminophen is the medication of choice. Aspirin and non-steroidal anti-inflammatory medications should be avoided during pregnancy. For more severe headaches, limited use of low-dose opioid (narcotic) medications may be appropriate. Most preventive medications should be avoided during pregnancy. If a preventive headache medication is necessary, beta-blockers are the most likely to be used; however that class of medication still has potential risk to the fetus. Close follow-up with your neurologist or gynecologist during pregnancy is important so that adjustments can be made in the treatment of your headaches.