Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 30-year-old woman is evaluated for episodic migraine without aura that first presented in high school and has persisted into the third trimester of her current pregnancy. The headache attacks occur two to four times monthly and last 12 to 24 hours. She experiences moderately severe pain, significant nausea, no vomiting, and pronounced photophobia with most of the attacks. Her only medication is prenatal vitamins.

Physical examination findings, including vital signs, are normal.

Which of the following is the most appropriate treatment?

A: Acetaminophen
B: Amitriptyline
C: Naproxen
D: Oxygen
E: Rizatriptan

MKSAP Answer and Critique

The correct answer is A: Acetaminophen.

This patient should be treated with acetaminophen. Although migraine often improves during pregnancy, many women continue to experience episodes throughout all three trimesters. Nonpharmacologic therapies are emphasized, with hydration, rest, and local application of ice all effective means of treating an acute attack. For pregnant women who require medical management, only medications with appropriate FDA and Teratogen Information System (TERIS) ratings for safety of use should be selected as treatment during pregnancy. The drug of choice for this patient is acetaminophen, one of the few acute migraine agents rated pregnancy category B (no evidence of risk in humans but no controlled human studies) by the FDA. This is often combined with metoclopramide or ondansetron, also both category B drugs, if nausea or vomiting is a significant migraine-related symptom during pregnancy.

Recent population-based studies have documented an increased risk of adverse pregnancy outcomes for women with migraine, including low-birth-weight, preterm deliveries, eclampsia, and placental abruption.

Amitriptyline is rated category C (risk to humans not ruled out) by the FDA. Although it is effective in migraine prevention, the low monthly migraine frequency in this patient does not warrant preventive pharmacotherapy.

Naproxen is rated category B by the FDA in the first two trimesters of pregnancy, but concerns of fetal patent ductus arteriosus and maternal bleeding at delivery render this option unsuitable for third trimester management of migraine.

Oxygen may be effective in the management of acute cluster headache, but no significant data support its use in acute migraine.

Rizatriptan carries an FDA pregnancy rating of category C and should be used in pregnant patients only after category B options have been exhausted.

Key Point

• Acetaminophen, combined with metoclopramide or ondansetron for relief of the nausea and vomiting that can accompany migraine, is appropriate for use in pregnant women with migraine because these agents are unlikely to have a negative effect on the fetus.

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