Clinician perspectives on migraine control during pregnancy

The current literature demonstrates the strong association between migraine and both maternal and fetal complications. Therefore, obtaining more knowledge on the awareness and comfort levels of women’s healthcare providers on migraine treatment is critical in the process of recommending the most effective treatments. In addition, understanding the profiles of certain medications prior to conception is essential as patients may benefit more from information related to nonpharmacological approaches, focused on changes in lifestyle.

Brian Groberg, MD, FAHS

Women’s healthcare providers and headache specialists have their own different biases for recommending treatments to pregnant patients with migraine based on their own individual experiences. Hence, contrasting opinions come up in conversations for patients seeking out treatment for their migraines during pregnancy. Coauthors Brian Grosberg, MD, FAHS, Stephanie Bakaysa, MD, and colleagues, recently published a survey study in Headache on 92 women’s healthcare providers, which identified different levels of comfort levels for migraine control during pregnancy.1

Grosberg, medical director of the Hartford HealthCare Headache Center in Connecticut, and Bakaysa, maternal fetal medicine specialist at Hartford HealthCare Medical Group, sat down in an interview with NeurologyLive®to discuss the results of the survey study. They both provided their clinical perspectives on the significance of the findings for patients with migraine and treating clinicians. Additionally, they talked about the surprising findings and the next courses of action.

Stephanie Bakaysa, MD

NeurologyLive®: What was the hypothesis coming into the research?

Brian Grosberg, MD: Migraine treatment during pregnancy can present significant challenges due to a lack of controlled clinical trials and risks associated with specific medications. Knowing this, along with the fact that an association exists between migraine and both maternal and fetal complications such as preeclampsia and preterm birth, makes understanding women’s healthcare providers’ treatment practices for pregnant women with migraine even more important, and that was the objective of this study. In addition, we also wanted to see how women’s healthcare providers’ treatment and comfort level in pregnancy compared with headache specialist’s management of migraine during pregnancy.

We sent a survey to over 400 women’s healthcare providers asking about their practice patterns as well as their comfort level when it comes to using specific, acute and preventive treatments in pregnant women with migraine. Nearly 100 women’s healthcare providers, the majority of which specialized in general obstetrics and gynecology, completed the survey. The majority of respondents reported feeling comfortable on some level recommending or continuing acute treatments (especially acetaminophen and caffeine) for pregnant patients with migraine. However, they felt less comfortable with recommending preventive treatments but more so with continuing an already established preventive treatment. In the end, this study helped to highlight the variability in comfort levels with specific acute and preventive treatment approaches while also calling for the importance of further studying and enhancing the practice and knowledge of women’s healthcare providers who frequently care for pregnant women with migraine.

What do you think were the major take-home points from this study?

Stephanie Bakaysa, MD: Over one-third (35%) of respondents counseled on migraine treatment once the patient became pregnant. Only one-fourth (26%) of respondents indicated that they had counseled women on migraine treatment in pregnancy as early as before pregnancy contemplation. This is in contrast to nearly two-third of headache specialists who start counseling women on migraine treatment in pregnancy as early as before pregnancy contemplation. Nearly two-thirds of women’s healthcare providers reported feeling somewhat or very comfortable with both recommending and continuing acute treatments. Highest comfort levels were with acetaminophen (100% for prescribing and continuing) and caffeine (94% for prescribing and 91% for continuing). Higher levels of discomfort were reported with triptans (88% rarely or never prescribe during pregnancy).In contrast, just over half of the headache specialists were somewhat or very uncomfortable using triptans.

Only 40% of women’s healthcare providers reported feeling somewhat or very comfortable with recommending preventive treatments. This is in contrast to nearly three-fourth of headache specialists who were somewhat or very comfortable recommending preventive treatments. Nearly two-thirds of women’s healthcare providers felt somewhat or very comfortable with continuing preventive treatments. Highest comfort levels were reported with the use of magnesium (69% comfortable prescribing and 82% comfortable continuing) and nonpharmacological approaches (70% comfortable prescribing and 84% comfortable continuing)

Nearly 80% of women’s healthcare providers were uncomfortable prescribing nerve blocks and neuromodulation devices. This is in stark contrast to headache specialists where three-quarters were very comfortable with nerve blocks and more than half were very comfortable with neuromodulation devices. Nearly 40% of respondents reported that they typically refer to neurologists or headache specialists for migraine treatment during pregnancy.

What do these findings mean for the future of pregnant patients experiencing migraine?

Brian Grosberg, MD: These results could suggest that, while it’s critical for patients to be well-informed as to safest practices prior to contraception, this may be an unlikely occurrence judging by only one-quarter of women’s healthcare providers in this study reported having counseled women on migraine treatment in pregnancy prior to pregnancy contemplation.Women may be unaware of the fact that they may need to be weaned off their preventive medication prior to contraception attempts. Moreover, pregnant women or women contemplating pregnancy may benefit from information and/or referrals related to lifestyle changes and non-pharmacologic treatments that could help reduce the frequency and/or intensity of migraine attacks during pregnancy. However, judging by the number of women’s healthcare providers who waited until the patient was already pregnant to counsel on migraine treatment during pregnancy (35%) compared to those who counseled on it prior to pregnancy contemplation (26%), it could be likely that many patients with migraine are missing out on this necessary and important education.

How generalizable are these results?

Stephanie Bakaysa, MD: Seeing as this study was conducted in a geographic area where numerous headache specialists and headache centers are located, the generalizability of these results to other areas of the country or world may be limited. Additionally, the study was limited to select women’s healthcare providers in specific clinical locations in CT; therefore, results may not be generalizable to other geographic regions, clinical settings, or types of healthcare providers.

Based on the results, did you find anything the stood out to you or was surprising?

Brian Grosberg, MD: Yes, the vast majority of women’s healthcare providers in this study reported feeling uncomfortable with peripheral nerve blocks and the use of neuromodulation devices.This view is divergent from headache specialists who favor the use of both of these treatment options in pregnant women with migraine. Nearly three-quarters of women’s healthcare providers reported higher rates of comfort around the use of caffeine and butalbital-containing analgesics compared to a study done by the American Headache Society where nearly 90% of headache specialists were somewhat or very uncomfortable with butalbital-containing compounds. This is surprising considering the use of caffeine and butalbital medications may be associated with fetal risks, including low birth weight, heart defects, and infant withdrawal, depending on the time period of maternal use and amount consumed. Additionally, American College of Obstetricians and Gynecologists practice guidelines recommend against the use of combination products containing butalbital during pregnancy, in part due to the risk of medication overuse headache and addiction.

What do you think should be the focus for future investigations with migraines during pregnancy?

Stephanie Bakaysa, MD: The results from this study highlight areas where additional headache medicine education would likely be beneficial in women’s healthcare. Moreover, these results support the continued need for the development and implementation of treatment guidelines for migraine during pregnancy.

Transcript edited for clarity.

This article was originally published by our sister publication Neurology Live.

Reference
Verhaak A, Bakaysa S, Johnson A, Veronesi M, Williamson A, Grosberg B. Migraine treatment in pregnancy: A survey of comfort and treatment practices of women's healthcare providers. Headache. 2023;10.1111/head.14436. doi:10.1111/head.14436