Headaches in Pregnancy (16 Feb 2026)

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Dr Aoife Duignan (AD): Hello and welcome to this episode of Clinical Conversations, brought to you by the Royal College of Physicians of Edinburgh Trainees and Members Committee. My name is Aoife and I'm a member of the Trainee and Members Committee and a geriatric medicine and stroke registrar in Edinburgh. And today, I'm delighted to be joined by Doctor Mireia Moragas, who is a consultant neurologist and stroke physician working in NHS Lothian. She trained in Spain as a consultant neurologist, which also includes training in stroke medicine, and has developed a special interest in headache and stroke. She moved to the UK in twenty eleven and has been working as a consultant in Edinburgh, where she runs the Headache Clinic in the Royal Infirmary, and has kindly agreed to speak to us today about the management of headache in pregnancy, which I think is something that provokes anxiety for a lot of those who are medical registrars called to the Labour ward. So, thank you for joining us today.

Dr Mireia Moragas (MM): Thanks for inviting me.

AD: So, I suppose let's start at the beginning. What goes through your head when you're contacted by someone who has a lady who's pregnant, who's presented to them with headache? How do you approach that scenario?

MM: So, I think it's important to say that the approach is exactly the same as the approach with anybody who presents with headache. So, the way I start is by with any person with headache is I want them with a history to answer five main questions. So, the characteristics of the headache, the temporal pattern, the alleviating and worsening factors, associated symptoms and triggering factors. And mostly with these I've got a very good idea of what is going on. Then a sixth question will be treatment received. But this is most to consider a treatment eventually. But the approach is exactly the same. Clinical history gives you the main diagnosis. Physical examination is very important, and there are some things to bear in mind in women who are pregnant. And then investigations is less important. It doesn't give us the diagnosis, but it helps to rule things out. So, the clinical history usually I let the patient speak first, and they tend to give you the main answers to these five questions. But also, it helps to know what they are most concerned about. So, some people start by saying, so I've got this headache and this is the diagnosis I've been given. But I am concerned about this, and you know how to deal with it. Whereas other patients tell you I've had this headache since I was a child, it's just completely ruling my life because it's so severe I get vomiting. I had to go to bed and lie down. So, you know, with that it's just giving you quite a few clues. So, in terms of temporal pattern, things that I want to hear about is this a long-standing headache? Is this a new onset headache? If it is a long standing, is it intermittent is a constant. And if it is intermittent, how long does it last for. And the frequency. And then also I want to know about the onset is its sudden onset. And I don't take the word of patients as sudden onset. I ask father is it from the beginning till the maximum intensity. How does it take? Is it five minutes? Is it an hour? So, as we know, the definition of thunderclap headache is from onset to peak less than five minutes. And then often people will say, as if I was bang with a bat at the back of the head or something like that. So yeah, the temporal pattern will give us an idea whether this is a long-standing headache or it's a new onset. If it's long standing, is that attacks are short lasting or lasts more than four hours. And the frequency and that really helps you to. Is this a migraine? Is this a more cluster type headache? Is this more neuralgiform short lasting or this is a constant daily headache. And then if it is intermittent migraine like will give you an idea of the pattern. So how frequent it is, how many headache days per month does this person have and will help when it comes to prevention? Then the characteristics of the headache. That's also very important to differentiate between the main primary headaches. So, a bilateral headache a unilateral headache the intensity people can do zero to ten. Or you can do mild moderate severe depending on what the headache stops you from doing as a pulsating which is a characteristic of migraine. Is it excruciatingly unilateral? Characteristic of a cluster or is it stabbing like or sharp like? Electric shock like. More characteristic of trigeminal neuralgia. Associated symptoms again important for diagnosis of primary headaches or nausea and vomiting. Photo and phonophobia osmophobia as well. Or are there ipsilateral autonomic symptoms or are there other symptoms like weakness. Weakness would be an alarm, a red flag, or is it, you know, visual sensory aura, dysphasic aura that also helps with the diagnosis and classification. Triggering factors is different than worsening factors. So, if you don't have a headache, what do you do that triggers the headache? Coughing sneezing straining in the loo that that points towards Valsalva induced headaches, which can be a red flag or can be associated to primary headaches as well. So, Valsalva induced headache. Headache associated to sexual activity. Exercise induced headache. Then worsening and alleviating factors. So, a headache that improves sleeping that is usually, you know, characteristic of migraine. Headache that worsens with coughing or sneezing or lying down. Although we can see this in migraine that would be symptoms that could indicate raised intracranial pressure. So, you need to bear that in mind. Or headache that only happens or that gets much worse when standing up. That could indicate low intracranial pressure. And finally, treatments received is important to ask about what preventive medication people have had, but also if they take any kind of painkillers, how frequently they take them, because. that can indicate a complication of a primary headache, which is medication overuse headache. So, when the patient talks to you and then you ask further questions to the patient, and you get that you do have a good idea of what is going on by then, obviously it's important to know about previous medical history. We always do that. But when it comes to the headache, those are the main questions.

AD: So, it helpful ways to go through that structure of thinking about the key features of a headache. I think it's always so useful to get a refresher in thinking about, as you say, that, thinking about the characteristics and pattern and triggers and associated symptoms. I think you've touched on a few things there about things that would make you worried, and things that would also reassure you when someone's presenting to us with a headache. And I suppose in pregnancy, I think a lot of us are more anxious about missing things in a pregnant patient. It was. What's the typical course of migraines for someone in pregnancy? I know we know that some conditions tend to be exacerbated or often go into remission during pregnancy. Is there a typical pattern for migraines in pregnancy?

MM: Yes. So, it's worth saying that migraine without aura and migraine with aura may behave differently during pregnancy. The vast majority of women who suffer with migraine without aura. With pregnancy, they will see an improvement of the migraine frequency and severity during pregnancy, especially towards the second and third trimester and then after delivery. Because of the lack of sleep and other hormonal changes, some women might find that it gets worse, or we do think that lactation is actually a bit protective. So, they might carry on with this improvement until they stop breastfeeding. It doesn't always happen though. In women with migraine with aura, the Mirena headaches may not improve during pregnancy, and they can be quite difficult to treat. And also, some women who previously had migraine with aura and the first aura during pregnancy. And that can sometimes be a reason for concern. But really, when a patient with established migraine presents with typical aura during pregnancy, I think it's unlikely that this is going to be anything else than their migraines. So, one of the points of our guideline is the simple fact that a pregnant lady presents with their first order does not necessarily mean that you know they've had a stroke or anything else.

AD: And a nice follow on from that is thinking about what are, I think the guidelines refer to red flags and green flags. I don't know if you might be able to help us work through some of those.

MM: Yeah. So, in the national headache pathway and the maternity network pathway, the fed is likely in these red and green flags, but only slightly. The concept is the same. So, we do have a set of red flags that which indicate the possibility of a secondary headache. And that you might need to rule that out. Whereas we've got also a set of green flags that can reassure you that you're dealing with a primary headache. So, when it comes to Two red flags. They're pretty similar to what you know with traditionally called red flags. So, a change in headache. Character of pattern. Bearing in mind that, you know, migraine can sometimes worsen during pregnancy, but there is a clear change in the character. So, the headache used to be unilateral and now is bilateral constant and progressive. That would be a red flag if there are clear characteristics of raised intracranial pressure. So, the headache now gets worse when lying flat, or it gets much worse with coughing and sneezing. A new daily persistent headache for more than seventy-two hours. That's always a red flag. In pregnancy, blood pressure is especially important. So, if the headache is associated to elevated blood pressure, that would make us think of secondary causes. If it's unusually severe or thunderclap presentation, Obviously, that's a red flag. Abnormal neurological examination. That's a red flag. Associated systemic disorders, especially those with associated with thrombophilia or clotting problems. We would be careful with those. Then headache brought with a physical activity may also indicate raised intracranial pressure or a valvular mechanism. Cognitive change A behavioural disturbance will make us think about possibility of a space occupying lesion, and significant recent history of hyperemesis and dehydration will also be a red flag. So, although I approach a headache in diagnosis and management in pregnancy the same as in the non-pregnant population with women in pregnancy, I always have a bit less threshold to think about cerebral sinus thrombosis. Another secondary cases of headache for example eclampsia and pre-eclampsia. So yeah, when we have a thunderclap headache we may think about subarachnoid haemorrhage but can also happen in reversible cerebral vasoconstriction syndrome or even trivial sinus thrombosis when the headache is worse when lying flat, or there are raised of signs of raised intracranial pressure. I will think of sinus thrombosis, but also idiopathic intracranial hypertension. So, when there are symptoms of behavioural change, cerebral sinus thrombosis or a space occupying lesion, it will be in my mind. And also, headache plus seizures. Headache plus cognitive change It will be something to indicate several sinus thrombosis and space occupying lesion. Now another thing not so much during pregnancy, but in the postpartum, especially if there has been epidural anaesthesia, is that if the headache is much worse when standing up and improves when lying flat could indicate low intracranial pressure, which can happen after epidural anaesthesia if there has been a total puncture. So that's another thing to bear in mind, especially after delivery.

AD: I think that's a really helpful reminder to us of the things that we need to be concerned about and worry about, and I suppose just what we're touching on those at the moment. Obviously, a lot of those things that you've alluded to are going to go on to need further investigation. And I think it's just those of us who aren't working regularly in maternity services are sometimes anxious about whether we should do Scans, we can consider what potential risks are. Or, for example, if some were to require a lumbar puncture, if it was concerned about a sub arachnoid haemorrhage. Whether it's safe to proceed with those. I don't know what guidance you would give to someone.

MM: This is a very important question. So, there's no reason why a lady who is pregnant should not have a CT head. If we consider it's clinically appropriate. So sometimes I've seen comments on the notes saying, oh, we're not going to do a CT head because she's pregnant. That's not right. Okay, so CT brain and CT brain with contrast are safe in pregnancy and have the same risks as they would have in a non-pregnant person. So, for the iodine contrast, you have to bear in mind the renal function. But if the renal function is normal and in a pregnant lady it should be. It is perfectly safe. So, more reasons why if it is clinically indicated that they shouldn't have it. MRI brain is considered safe as well. There are some concerns about MRI during the first trimester, because there was a concern that it could cause early loss in the first trimester, but that has not been proved. So, if we think that it needs to be done, there's no reason why it should not be done. Now, the only thing that we cannot give is Catalonia. Catalonia is not safe in pregnancy. Going back to the iodine contrast story, there have been some concerns that iodine could cause during pregnancy, could cause thyroid problems in the foetus, but that has not been proved in vivo. So, although I don't recommend to do CTV to every single pregnant lady who needs a scan. If you need to consider a contrast, I would give them a half encountered. You know women who say, absolutely, I want no contrast. If that's the case, and we need a venogram, you can have an Mr. Venogram without gadolinium. It's a bit more difficult to assess, but it can be done. And when it comes to lumbar puncture, there are no contraindications for lumbar puncture other than you have to obviously make sure that it is safe. So, if there is a space occupying lesion or severe Chiari malformation, then you would be more cautious.

AD: I think that's really helpful and reassuring, I think. I suppose it also is important to remind ourselves of that so that we don't under investigate as well as over investigate. For people who are pregnant, I suppose having thought about all of the red flags and some of the things that strike more fear, I think one of the really useful things you spoke about are the idea of green flags and things that can perhaps allow us to move forward with more confidence that this is a more benign type of headache, or perhaps a migraine or something similar. I don't know if you'd mind just reminding us.

MM: So, if you have a fully reversible episode of headache lasting between four hours and three days, especially if it's accompanied by nausea and sensitivity to lights and noises, that is the most reassuring feature. And you have ninety eight percent confidence that that's going to be migraine. So fully reversible headache episodes between four hours and three days accompanied by nausea photo and phonophobia. And people are headache free in between. That is migraine unless proved otherwise. Having previous history of migraine can reassure you but obviously bear in mind that people with migraine can also develop other conditions. Having a typical aura and a typical aura, we understand a fully reversible dynamic presentation. So progressive presentation lasting between five minutes and sixty minutes. So, no more than an hour of visual disturbance, sensory disturbance and dysphasia. So visual disturbance, positive symptoms ideally fast flickering flashing lights, zigzag lights that progress grow and then proceed gradually or sensory symptoms with that march where starts in the fingers and goes gradually over a few minutes through the arm, but it starts very orderly and progresses towards the face and lasts less than an hour. That's very reassuring, and that's considered typical aura with the Dysphasia is a bit more difficult because when you develop dysphasia, it's impossible to know whether it's sudden onset or not. However, usually Dysphasic aura is preceded by visual aura than sensory aura than dysphasia, and it lasts less than an hour. So, I recently had a friend who came to me and said, I've had this episode of Dysphasia. I'm extremely concerned. And she described typical visual aura, then sensory aura, then the dysphasia and then some mild headache afterwards. It's worth saying that each aura can last for an hour. So, you may have symptoms throughout three hours, but each type of aura will last for less than an hour. So that again would be reassuring and indicative of migraine with aura. And nowadays, when I approach a lady in pregnancy who may or may not have previous history of migraine but describes typical aura, I do not tend to investigate them unless there are other concerns.

AD: I think it's usually reassuring. I think we so often learn all the lists of things that we should be worried about, but it's less often that we can have some concrete things that we can really focus on to help us reassure someone that their symptoms are in keeping with what we might expect in a situation. So, I think that's really helpful to have gone over in terms of management in pregnancy, of this was an acute episode of migraine and then more preventative management because we were always trying to avoid the risk of harm with any medications we might use. I wondered if you could share with us how you best approach managing acute episodes.

MM: So yeah, there's no reason why we should not try to help women who are pregnant and are suffering with severe attacks or frequent attacks. Obviously, the first thing would be to ensure that there are no causes of concern. The main thing that I encounter in my patients who have migraine and become pregnant and the migraine gets worse, is high blood pressure. So that is one of the first things to treat. And we treat it with labetalol, with nifedipine. And usually when the worsening migraine is triggered by the hypertension, the migraine headache tends to get better in terms of acute medication for migraine. Sorry. Before I go into medication, one thing that is very important to remember is lifestyle changes. So regular hydration, regular meals, avoiding lack of sleep or excessive sleep, avoiding stress, which is often difficult if the person is working, but within what's possible. It's important to emphasize on these other measures, like, you know, a cold flannel around the forehead. That's things that women will in pregnancy will do. Because in general, women who are pregnant are scared of taking medication. So, it's important to be able to reassure them when all these lifestyle measures are not enough, that there are things that they can do and they can take safely. So, paracetamol one gram, it's lower, a patient is low weight, but one gram is safe. Sumatriptan is safe. Opioids are safe. But we don't use as first line. So, opioids are never used or should never used as first line treatment for migraine. Mostly because it worsens nausea. And we have other more effective treatment in terms of non-steroidal anti-inflammatories. A high dose of aspirin is not indicated during pregnancy or lactation, thus are definitely no go. And I warn all my patients ibuprofen may be used, but we recommend to avoid it after week twenty. Used to be twenty-eight, but more recently the guidelines have changed to week twenty of pregnancy to avoid the closure of the ductus arteriosus. So basically, paracetamol sumatriptan are safe. Ibuprofen may be taken up to week twenty codeine in exceptional cases, but we do not tend to use it as first line. And anti-emetics are important as well. So prochlorperazine and metoclopramide are safe during pregnancy and widely used. And they do have not only an anti-emetic effect, but also an anti-migraine effect. So, the combination of paracetamol and prochlorperazine or sumatriptan and prochlorperazine can be very useful as acute migraine treatment. Now whenever we recommend all these it's important to remind the patient that we do not recommend it more than two days per week on average, or ten days per month, and this is to avoid medication overuse headache.

AD: That's really helpful. Summary. Reminds us of all the things we can use as well as to avoid. It was where someone has a history of more frequent or severe migraine. They may be on prophylaxis, and they might approach someone saying that they're contemplating pregnancy or have found out they're pregnant and wonder about what they should be doing with some of the common treatments that they might be receiving. And what would your approach be for those ladies?

MM: So preventive medications, we are a bit more limited. We know that beta blockers. So, propranolol at low doses, which is about twenty milligrams twice a day, which is not a big dose when it comes to preventive medication, and tricyclics, mostly amitriptyline, up to fifty milligrams per day that is considered safe during pregnancy up until the third trimester. We recommend to withdraw it in the third trimester the beta blockers, because it can cause hypoglycaemia and bradycardia in the foetus and the newborn baby, and amitriptyline because it can cause withdrawal effects and it can be oversensitive in the newborn, especially if low weight. So my approach is if somebody has migraine and become anaemic on beta blockers or amitriptyline and becomes pregnant, we tend to reduce the dose to what is recommended during pregnancy and warn them that they will need to withdraw it when approaching the third trimester, and I always planning to do it before the third trimester because you want a gradual withdrawal. I mean, some women in that situation become pregnant and the headaches become better anyway, so that's the more reason to withdraw it. Other things like candesartan, topiramate, those are contraindicated during pregnancy. And actually, for topiramate nowadays with a pregnancy prevention program where women have to be on effective contraception, if they are on topiramate and they are under age fifty-five. Other things like the new treatments. So, a tojapan rimegepant all the CGRP monoclonal antibodies, those are new medications. There is not enough evidence whether it's safe or not. And they should be avoided with the caveat that atosiban rimegepant the life, the GIP and the half life is short and therefore it's out of your system within three and a half days. We say a week to be safe. Whereas the monoclonal antibodies, the half-life is a month, and therefore you need at least five months for it to be out of your system. So that will be important when planning pregnancy. Other things that we use in pregnancy that we may not use outwith pregnancy are a low dose of aspirin. So, although a high dose of aspirin to treat migraine is contraindicated in pregnancy and lactation, a low dose of seventy-five or one hundred and fifty milligrams of aspirin daily as a preventive medication has been used, especially for migraine with aura. The evidence is very old, but there are some RCTs that show that a low dose of aspirin may reduce the frequency of migraine with aura, or even the frequency of aura Alone, and it is widely used by obstetricians. If the pregnant lady has frequent migraine, in my experience, it's not that effective. But it's worth trying, especially if there are other reasons for using it. Another thing that we use is greater occipital nerve block. Greater occipital nerve block. So, the greater occipital nerve is the nerve that comes from the C1 c2 nerve roots. And it gives the sensation to the back of the head medially. So, we can target that with lidocaine and steroids. So, depo-medrone. Doing a nerve block. But that causes a numbness in the area for two or three hours. But in some primary headaches migraine cluster it can reduce the frequency and severity of the headache. The mechanism of action is considered to be retro feedback because the cervical nerve roots are closely related to the trigeminal nerve, and the trigeminocervical complex is the vehicle of pain in migraine and trigeminal autonomic cephalalgia. So, by targeting the owner, it can improve the frequency and severity. The evidence is relatively poor, and this is because it's difficult to do a randomized controlled trial when you're using lidocaine. But there is increasing evidence that it may be useful. It's not a good long-term treatment, but when you don't have anything else during pregnancy and it is quite a safe procedure, it's something that we can use. Ideally no more than every three months, but during pregnancy I even use it every four weeks if necessary. It is effective in about forty percent of people with migraine, and it can give you relief for just a few weeks or even three four months. So, it's definitely worth trying. And sometimes I use before pregnancy to see if it's an option or not. The lidocaine is definitely safe. Local lidocaine is definitely safe. The steroid part of it, there is a bit of controversy. So, we know that high doses of steroids in the pregnant woman may affect the skeletal development of the foetus. Really what we use in the cone block is minimal quantities and what goes systemically. Although we know there is a systemic effect, it's likely to be negligible. But I always offer this to the pregnant lady so they can choose whether to go just with lidocaine or with lidocaine and steroids. We think that lidocaine and instead. It is most likely to be effective, especially in cluster headache, but also in migraine, and that's quite a useful option when the patient is really struggling and there's nothing else.

AD: I think it's really useful to know about these treatments so that even if it was as a general physician, it might not be something, but within your toolkit to be able to offer to know when someone might benefit from input of specialist neurology so that they can try to achieve some improvement in their symptoms during pregnancy. You've mentioned cluster headache a few times. What should we be thinking about in terms of cluster headache in pregnancy?

MM: Cluster headache is a rare headache is even rarer in women, so it's unlikely that any of us is going to encounter it during pregnancy. But it happens. And when it happens, it's really important to identify it so we can manage the patient Appropriately so. Typical cluster headache is a unilateral, excruciating headache, the worst pain known to humankind that lasts between fifteen minutes to three hours on average. And the patients during the attack are agitated. So rather than trying to lie down in a dark room, they will be pacing around, they will be rocking, and they will be banging their head. But in general, active and also, they are accompanied by ipsilateral autonomic symptoms. So red eye, TD, ptosis and miosis, blocked nose, runny nose, sweaty face or red face. Blocked ear. So, when you encounter somebody with brief episodes of severe unilateral headache and they are agitated pacing around, or they have autonomic symptoms on the same side site that meets and they are usually well in between. You need to consider this is cluster headache. What can we do for them? Subcutaneous sumatriptan. Acute treatment. High flow oxygen and then referral to neurology for management. And what we will do with these patients are most likely. And we will consider whether verapamil is necessary. But we can use it during pregnancy.

AD: It's so helpful for those with a history. So, the important and common headaches that we should think about migraine is the most common type of headache and how we can manage that. And I suppose whenever we're looking after someone who is pregnant would always be wanting to communicate with our obstetric colleagues and midwifery team to make sure that we're all working on the same page together. I think sometimes those of us working in general medicine might not always know where to start in terms of looking for information about prescribing in pregnancy, or having any places that you find useful to look when you're trying to think about prescribing in pregnancy or giving patients information about what might be safe in pregnancy.

MM: So, we created the National Headache Pathway, which is available online. And basically, I was responsible for writing the management of migraine during pregnancy. And other easier, easy to find resource is the href help for Lothian the href help document of management of migraine in pregnancy. So, I created that and it's an A4 document where it tells you what safe during pregnancy and lactation. And another thing to bear in mind as well is so what treatments if a woman is not pregnant but is on migraine treatment and is considering to become pregnant? So that's another thing that is reflected in those pathways.

AD: That's really helpful because I think knowing a starting point to get advice, particularly when someone's working active hours, it's always useful to have a guideline in the back of your head that you don't necessarily need to know every bit of the guideline, but just to know where to find it and know that someone has all that thoughts and information together for you. I've learnt, and I suppose consolidated a lot of things in speaking to you today, and I'm sure it'll be really useful for other people who might be caring for patients in pregnancy with headache. So, thank you so much for your time and speaking to me today. Have you got anything else you'd like to add before we finish?

MM: Yeah. One thing I haven't mentioned is Botox treatment. So many of our female patients are on regular Botox statesman, which is very effective, to manage their difficult to treat migraine. And it often comes to the question, well, you know, I'm considering becoming pregnant. What can I do? And it's worth mentioning that Botox is not licensed during pregnancy or lactation. However, we have experienced for many years, and we have a register that shows that many pregnancies have happened when patients were undergoing Botox treatment. And it's quite reassuring to see that that data shows there is no increase in foetal malformations or pregnancy losses during any stage of the pregnancy. For patients who have undergone Botox treatment during pregnancy. So, although it's still off license, if I have a patient with very difficult to treat migraine. Who is on Botox treatment and wishes to become pregnant? I do tend to continue with the treatment until they find out that they are pregnant, and then we can take it from there. And I do have an most headache clinics do have some patients who have undergone Botox treatment despite the pregnancy. But this is why, very carefully discussing the fact that we don't know for sure.

AD: I think that really highlights the importance of communicating and seeking specialist's advice. When we have patients who have really difficult to control symptoms, that hopefully people might have some more confidence in dealing with, some of the more straightforward presentations and in investigating and approaching a patient with headache might be presenting it of ours. But I think throughout our conversation, we really being reminded that the management of headache and persistent headache can be complex and debilitating for patients, and that it's important that we make sure that they are getting good advice and support through their pregnancy to make sure that they're not just avoiding medications which might cause harm, but also receiving treatments which can be really beneficial for them in staying well during their pregnancy and afterwards.

MM: Yeah. If I could summarize, what's my approach for pregnant ladies with a headache is migraine, especially with aura is common in pregnancy, but paracetamol and sumatriptan are safe during pregnancy. But migraine prevention is available and should be discussed in patients with headaches, difficult to treat headache and pregnancy that the management of headache and the approach to headache should not differ from those who are not pregnant, and that CT venogram MRI without contrast and lumbar puncture are safe during pregnancy and should be offered when clinically indicated.

AD: I think that's such a useful summary, reminding us of all the key points that we've spoken about today. I'm so grateful for your time, and we'll put some links in the show notes for anyone who's listening to those guidelines that have been referenced. And we'll also put in links for useful prescribing resources as well for patients in pregnancy. So, thank you very much, Doctor Moragas.

MM: Thanks for inviting me.