Migraine tied to adverse pregnancy outcomes

Pregnant women with migraine appear to have an increased likelihood of experiencing pre-eclampsia, low birth weight, peripartum mental illness, preterm birth, and placental abruption, according to a study presented at the recent RCOG 2023.

“Migraine is common in women and prevalence peaks during the reproductive years. Understanding the impact of migraine and associated treatments on pregnancy outcomes remains very important,” said the researchers, led by Katherine Phillips from the University of Birmingham, Birmingham, UK.

Phillips and her team conducted an umbrella review of systematic reviews “to identify and appraise higher level evidence reporting on the association between migraine and its treatments and pregnancy outcomes, to consolidate evidence from systematic reviews and meta-analyses using narrative synthesis and, where appropriate, quantitative synthesis, and to update existing systematic reviews and meta-analyses, where necessary.”

The team searched the databases of Medline, Embase, and Cochrane from inception to 27 October 2022 for systematic reviews with or without meta-analyses of the association of migraine and migraine treatments with pregnancy outcomes. They used the AMSTAR2 tool for quality appraisal and an established framework to determine whether included reviews were eligible for update.

The criteria for an update were as follows: (1) the key search terms from the search strategy identified new studies that met the eligibility criteria, and (2) the findings could potentially alter the conclusion of the review. Overall, only four studies were included in the umbrella review.

Migraine significantly correlated with a greater possibility of having pre-eclampsia (pooled adjusted odds ratio [aOR], 1.94, 95 percent confidence interval [CI], 1.37‒2.76), low birth weight (pooled aOR, 95 percent CI, 1.03‒1.34), and peripartum mental illness (pooled aOR< 3.54, 95 percent CI, 2.24‒5.59). In addition, women with exposure to triptans had a higher risk of miscarriage than those without migraine (pooled aOR, 3.54, 95 percent CI, 2.24‒5.59). [RCOG 2023, abstract PP.0007]

Of the four included reviews, one that examined the association between migraine and pre-eclampsia, preterm birth, placental abruption, small for gestational age, and low birth weight was eligible for an update. The search strategy used by this review was repeated from the date of their search until 24 November 2022, with seven studies meeting the inclusion criteria.

“The meta-analyses were updated for preterm birth and placental abruption,” the researchers said. “[M]igraine was associated with an increased odds of preterm birth (pooled OR, 1.23, 95 percent CI, 1.17‒1.30) and placental abruption (pooled OR, 1.66, 95 percent CI, 1.19–2.32).

Migraine treatment

In a separate review, researchers led by Siri Amundsen from the Department of Laboratory Medicine, University Hospital of North Norway, Tromsø, Norway, stressed that nonpharmacological strategies are always the first-line treatment for migraine in pregnancy and should be used to complement any necessary drug treatment. [Nat Rev Neurol 2015;11:209-129]

The preferred medication for acute treatment throughout pregnancy is paracetamol, but sporadic use of sumatriptan may be considered if paracetamol is not effective. Other nonsteroidal anti-inflammatory drugs such as ibuprofen can also be used under certain conditions, but their intake during the first and third trimesters was associated with some risks and contraindications, according to the researchers.

“In women contemplating pregnancy, counselling is essential to promote a safe and healthy pregnancy and postpartum period for the mother and child and should involve a dialogue addressing maternal concerns and expectations about drug treatment,” Amundsen and colleagues said.