Migraine

 Basically, let us be clear that there are two class of treatments for migraineous headache –which are applicable equally to in preg and in nonpreg state (even in men too).  One class of drugs is A) prophylactic drugs and B) the second group of drugs for acute attacks drugs. This classification should    be made clear whoever are in charge of the case.

Currently we are discussing the safety of drugs designed for “prophylaxis of attacks” of headache. Regarding safety of A) Amitryptiline (10-150 mg daily), B) Propranolol (Inderal)-as 20-80 mg   on TDS basis, or Metoprolol as   50-100 mg on BD schedule. Use of all such agents are safe in pregnancy (may read 24th Ed of Williams T B of Obstetrics, p. no 1189.  What does another Book remarks regarding selection of safe drugs in midtrimeser for women with Migraine?  The Hand Book of Obstetric Medicine Ed C Nelson-Piercy Ed 3^rd Ed p. 181, conclude that Codeine Po4 (if available in Indian market), Low dose aspirin, à Beta blocker first. If first , then add Tricyclic antidepressants a, The 4^th add-on will be , Calcium antagonists which are  very useful in pregnancy. . it is NOT prudent to prescribe prophylactic iv drugs too liberally, better to use the drug if emergency arises. The author, very rightly have also warned that use of beta blockers may cause FGR if used throughout preg, To conclude, will be as follows :-use Aspirin (first)  & later second best is to combine Beta blocker, and if fails then as prophylaxis the combination of aspirin, beta blocker and Tricyclic antidepressants. Beta blockers

 

  Not all headaches in pregnancy are related to PIH!! Pregnant women presenting at emergency with severe headache & relatives don’t disclose the past history of migraine!! May be confused with severe PIH, Sub -arachnoid haemorrhage (if headache is severe).meningitis  D/D of cerebral venous thrombosis. One goes on referring from one Deptt to other Deptt unless relatives disclose or doctor put direct Q about preexisting migraine. -which I have never probed. Even migraine can occur first time in after CS delivery and we may be confused with Post Dural puncture headache. Most cases of migraine do improve in pregnancy but may worsen too. Surprisingly it may appear for the first time in pre and may camouflage the obstetricians though I have never witnessed such “new onset Migraine in pre”. I don’t know the experience of fellow members... What about treatment in acute phase of migraine?  Intravenous drip, I V antiemetics, IV Opiods etc.

Treatment of acute phase with persistent vomiting, intense throbbing headache & severe photophobia in preg? What to do?? I V drip, I V antiemetics. Mag So4, once used in acute phase is not favoured   nowadays. Even serotonin receptor agonists which in earlier post I thought is harmful (teratogenic) have been occasionally used (possibly by compulsion) and so also Ergotamine in acute phase as temporary measure to tide  over the acute phase.

 

 

What else as prophylaxis of migraine ? But one should keep in mind that there are basically two types of treatment of migraine. A) Phramcological Tr(discussed above) and B) One is nonpharmacological Tr. e.g, 1) Biofeedback Techniques Acupuncture & transcranial  Magnetic stimulation, I have no experience on these methods.

I was surprised to know:-Drug for migraine or no drug: - Migraine itself increases the possibility of “Limb reduction defects” in foetus,–slightly if acute attacks occur in first 8 wks of pregnancy.

It is said that there is a distinct possibility of Platelate aggregation in men & women with migraine. Mechanism or Dynamics-is unknown:-May avoid OCP later because such women with aura are at an increased risk of Cardio-vascular Diseases at later life (May see -Medical Eligibility Criteria Book -A publication of WHOM) 5^th Ed