VALENCIA, SPAIN – Women who present with acute severe migraine during pregnancy are at increased risk for adverse pregnancy outcomes and should be seen in a high-risk pregnancy clinic, Dr. Tracy B. Grossman asserted at the International Headache Congress.
“We should not be seeing these patients in a regular ob.gyn./generalist’s office because oftentimes we need input from neurology, and we need extra surveillance for both the fetus and the mother,” she said at the meeting sponsored by the International Headache Society and the American Headache Society.
Dr. Tracy B. Grossman
Dr. Grossman presented a retrospective study of 90 consecutive pregnant patients who presented with acute severe migraine and obtained a neurology consult at Montefiore Medical Center, New York, where she is an ob.gyn. resident.
“These patients are different from most migraine patients because most migraine patients actually see improvement of symptoms during pregnancy. So this is a special group of patients with worsening and refractory migraine,” she noted in an interview.
Most were in their third trimester and had migraine without aura. Twenty-four presented with status migrainosus, a migraine for 15 or more days a month for more than 3 months.
Forty-nine of the 90 patients (54%) experienced one or more adverse pregnancy outcomes. Of note, the 28% preterm delivery rate was nearly three times the national average of 11% as reported by the March of Dimes. The preeclampsia rate was 20.5%, compared with a national rate of just 3%-4%. The 19.2% low birth weight rate was more than double the 8% national average. The cesarean section rate was 30.8%.
The study hypothesis was that the migraine-with-aura group would have higher preeclampsia, preterm delivery, and low birth weight rates, as has been reported by some other investigators in what is a sparse literature. Not so, Dr. Grossman said, because most of these patients didn’t have aura.
“So it can’t be purely an aura/vascular phenomenon that’s resulting in these adverse outcomes. These high rates of adverse pregnancy outcomes aren’t easily explainable. There’s something going on here that we haven’t teased out yet as to why these migraine patients are special,” she continued.
Their risk of adverse pregnancy outcomes wasn’t related to the headache medications they took. Sixty-two patients received a combination of oral and intravenous therapy with acetaminophen, metoclopramide, and dihydroergotamine. But 30% of patients were briefly on barbiturates, and 30% were on oxycodone or codeine; these are drugs of concern during pregnancy, yet there was no associated increase in adverse pregnancy outcomes, compared with the women who weren’t on those drugs or who indeed weren’t on any headache medications at all.
Dr. Grossman’s own therapeutic preference in patients with severe migraine in pregnancy is a peripheral nerve block with bupivacaine and lidocaine.
“It works for the majority of people – we don’t quite know why – and it’s a local therapy that avoids fetal exposure to systemic medications,” she observed.
Dr. Grossman reported no financial conflicts with regard to her study, which was carried out without industry support.