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The major concerns in the management of migraine in pregnancy are the effects of medication
and the disease itself on the fetus. Medication use should ideally be limited.
Paracetamol, metoclopramide, caffeine, codeine (or perhaps other opioids) can be used
during pregnancy, although aspirin, nsNSAIDs or coxibs may be of concern, especially during
the third trimester (Evers et al, 2006) (see Section 11.1 and Tables 11.1 and 11.2).
Ergot alkaloids and triptans are contraindicated in pregnancy (Steiner et al, 2007; Evers et al,
2006). In one study, the use of sumatriptan in early pregnancy did not result in a large increase
in teratogenic risk, but the possibility of a moderate increase in risk for a specific birth defect
was not excluded. Among sixteen infants who had major malformations, nine had been
exposed to sumatriptan; 1.3% of infants exposed to sumatriptan alone and 2.8% of infants
exposed to other drugs for migraine had such malformations (Kallen & Lygner, 2001). Ergot
alkaloids during pregnancy may disrupt feto‐placental blood supply and cause uterine
contraction, which can result in fetal injury or loss. Birth defects and stillbirths due to vascular
spasm have been reported. On the basis of current data, all ergotamines are contraindicated
in pregnancy and are category X (see Table 11.1).
Ibuprofen, diclofenac, metoclopramide or paracetamol are considered safe for the treatment
of migraine in mothers who are breastfeeding. There is no clear consensus on the safety of
triptans. Although the transfer of eletriptan or sumatriptan to breast milk is considered
‘negligible’, the manufacturers of most triptans recommend avoiding breastfeeding for at
least 24 hours postadministration (Steiner et al, 2007) (see Table 11.3).
Cluster headache and other trigeminal autonomic cephalalgias
Cluster headache is a rare primary headache disorder, presenting almost exclusively in males
with recurrent, acute episodes of brief, severe, unilateral, periorbital pain associated with
autonomic phenomena such as conjunctival injection and tearing.
Consensus guidelines for the treatment of cluster headache attacks recommended high‐flow
oxygen therapy or SC sumatriptan as therapies of first choice (May et al, 2006; Steiner et al,
2007). Acute steroid prophylaxis is recommended at the start of every cluster period (see
below), either with prednisolone (Steiner et al, 2007) or methylprednisolone (orally or
intravenously) (May et al, 2006), tapered over days to weeks.

Oxygen
Oxygen therapy may be useful in patients with cluster headache who have either a
contraindication to sumatriptan or experience several cluster attacks per day (Dahlof, 2002). CHAPTER 9
Although oxygen is recommended as a first‐line treatment (May et al, 2006; Steiner et al, 2007),
such recommendations are only supported by evidence from two small trials and clinical
case reports (Bennett et al, 2008 Level I). High‐flow oxygen provided symptomatic relief in
approximately 50% of patients with acute cluster headache (Fogan, 1985 Level II) (NNT 2; CI 1
to 5); approximately 76% of patients responded to normobaric oxygen therapy (Bennett et al,
2008 Level I). The presence of nausea/vomiting and ‘restlessness’ was predictive of a poor
response to oxygen (Schurks et al, 2007 Level IV).
Hyperbaric oxygen was no more effective than sham hyperbaric treatment in reducing the
frequency or duration of cluster headaches (Bennett et al, 2008 Level I); however, 83% of
patients with episodic cluster headache improved significantly with either treatment,
suggesting either a placebo effect or therapeutic benefit from the hyperbaric process itself
(Nilsson Remahl et al, 2002 Level II).

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