Beyond the Pain: Considering Migraine in Family Planning

NeurologyLiveOctober 2023
Volume 6
Issue 5

Migraine science continues to deepen the understanding of its impact, even beyond the pain and associated symptoms of the individual attacks, better equipping clinicians to meet their patients where they are.


Rashmi B. Halker Singh, MD, FAAN Associate professor of neurology, Division of Headache Medicine, and director, Headache Medicine Fellowship Program, Department of Neurology, Mayo Clinic, in Scottsdale, Arizona

Rashmi B. Halker Singh, MD, FAAN, is an associate professor of neurology at Mayo Clinic, where she also serves as the headache medicine fellowship program director, and faculty at Mayo Medical School. She is board certified in neurology by ABPN and headache medicine by UCNS.

At the American Academy of Neurology, she is the previous Chair of the Headache and Face Pain Section and a current member of the Science Committee, and has severed as course director, faculty member, and plenary speaker at the annual meetings. At the American Headache Society, she is a member of the Board of Directors, as well as codirector of the REACH program, current cochair of the Women’s Leadership Development Subcommittee, and codirector of the Scottsdale Headache Symposium annual meeting. She is also the deputy editor and online and social media editor for Headache, and an Editorial Board Member of the American Migraine Foundation.

She has been an invited speaker to many regional, national, and international meetings, and has numerous peer-reviewed publications, book chapters, and abstracts related to her fields of interest including migraine, women and headache, telemedicine, medical education, as well as topics related to diversity, equity, and inclusion.

Her many honors include the American Headache Society Above and Beyond Award for Service, Outstanding Course Director at Mayo Clinic, Top Faculty Members Award by Mayo Clinic School of Continuous Professional Development, Emerging Leaders by the American Headache Society, Mayo Clinic Commitment Against Racism Grant Recipient, and the Mayo Brothers Distinguished Fellowship Award.

WITH MIGRAINE BEING A disease process that disproportionately affects women—particularly those at the age when pregnancy is a consideration—it is now gaining recognition as an important part of pregnancy care, from being included more deliberately during discussions of prenatal planning to a shift in how we consider migraine management during pregnancy. I see this as a time of hope and renewed optimism, as we deepen our understanding of the impact of migraine, even beyond the pain and associated symptoms of the individual attacks, and better equip ourselves to meet our patients where they are.

Recently, data from the American Registry for Migraine Research (ARMR) revealed that up to 20% of women with migraine are choosing to avoid pregnancy because of their diagnosis.1 The reasons behind this decision vary, from apprehensions that migraine may make parenting more challenging to misconceptions about the disease process. Although these findings are striking and demonstrate the long-term personal repercussions of migraine, this information also can be helpful to clinicians, as we now have certain details about our patients’ concerns. For example, it can be important to ask relevant questions and initiate discussions when patients may hesitate to bring up these delicate topics. Decisions regarding pregnancy are not only personal but also time sensitive, so by sharing knowledge with our patients, we empower them to make these choices based on facts rather than fallacies. Consequently, these conversations can be an important therapeutic part of the patient-clinician relationship.2

Not only is there a greater emphasis on having these conversations directly with patients, but research also highlights the importance of collaborative care between health care professionals and ways in which this can be beneficial.3,4 For instance, the majority of women receive their migraine care from primary care providers, including those who focus on women’s health care, rather than from neurologists or headache specialists. A recent survey of women’s health care providers identified several treatment knowledge gaps in migraine management, as well as an interest in furthering education on these topics and areas in which partnering with specialists could optimize patient care. From the neurologist perspective, these reports suggest we may be able to better support our primary care colleagues by taking a more hands-on approach when comanaging migraine.

Underscoring the need for greater migraine management options during pregnancy, the 2022 Headache Members’ Choice Award for best paper was given to the first systematic review on the management of primary headaches during pregnancy, postpartum, and breastfeeding.5,6 Although this positive response from the medical community signaled the need for increased research in this space, as the systematic review results were based on 16 studies and 26 other systematic reviews, there were other important findings.7

Notably, consistent with registry data, this manuscript suggested that triptans are likely a safer option in pregnancy and have changed the way many headache specialists care for those with migraine during pregnancy. This current change in perspective, emphasizing a need to find additional treatment options during pregnancy, is accompanied by an acknowledgment that not treating migraine during pregnancy can be associated with increased complications, from dehydration to preeclampsia, to preterm delivery and low– birth weight infants. Migraine can have additional impacts, as being unable to go to work during a migraine attack may mean the loss of a paycheck, and financial stressors can be significant, particularly during pregnancy. Furthermore, although many women will experience migraine improvement during pregnancy, the vast majority will not be completely free from attacks and are interested in a plan for management.8 For all these reasons, how to best treat migraine during pregnancy has become a topic of considerable importance. Having updated data available has been very welcome as we reframe migraine management for our pregnant patients.

Looking ahead, we can see additional paradigm shifts toward optimizing migraine management during pregnancy and breastfeeding. Reports are emerging suggesting that onabotulinumtoxinA might be a reasonable preventive treatment to offer our pregnant patients with chronic migraine,9,10 and a recent retrospective study also did not demonstrate harm with one of the available neuromodulation devices.11 These studies are just a few examples of the current momentum to provide our patients who are pregnant with a wider range of options for management. As we think about what it means to live without the influence of this chronic condition in all aspects of life, the ARMR data provide a prime example of the hold migraine has on decision-making related to pregnancy. We can imagine a future where women are able to make this important, time-sensitive life decision based on what is best for them, without the influence of migraine, and have available comprehensive care options for management if needed. With the current research, from the work on increasing education and strengthening collaborative care with women’s health care providers to exploring pharmacologic and nonpharmacologic treatments, maybe that future is not so far off.

1. Ishii R, Schwedt TJ, Kim SK, Dumkrieger G, Chong CD, Dodick DW. Effect of migraine on pregnancy planning: insights from the American Registry for Migraine Research. Mayo Clin Proc. 2020;95(10):2079-2089. doi:10.1016/j.mayocp.2020.06.053
2.Halker Singh RB, Sirven JI. Migraine headaches and family planning: what we think we know. Mayo Clin Proc. 2020;95(10):2054-2056. doi:10.1016/j.mayocp.2020.08.026
3. O’Brien HL, Halker Singh RB. Breaking down barriers to care:understanding migraine knowledge gaps among women’s healthcare providers. Headache. 2021;61(1):7-8. doi:10.1111/head.14034
4. Verhaak AMS, Williamson A, Johnson A, et al. Migraine diagnosis and treatment: a knowledge and needs assessment of women’s healthcare providers. Headache. 2021;61(1):69-79. doi:10.1111/head.14027
5. Saldanha IJ, Cao W, Bhuma MR, et al. Management of primary headaches during pregnancy, postpartum, and breastfeeding: a systematic review. Headache. 2021;61(1):11-43. doi:10.1111/head.14041
6. Saldanha IJ, Cao W, Bhuma MR, et al. Systematic reviews can guide clinical practice and new research on primary headaches in pregnancy: an editorial on the 2022 American Headache Society Members’ Choice Award paper. Headache. 2022;62(7):774-776. doi:10.1111/head.14332
7. Hamilton KT. The evidence (or lack thereof) for treatment of primary headache during pregnancy and lactation. Headache. 2021;61(1):9-10. doi:10.1111/head.14047
8. Burch R. Epidemiology and treatment of menstrual migraine and migraine during pregnancy and lactation: a narrative review. Headache. 2020;60(1):200-216. doi:10.1111/head.13665
9. Brin MF, Kirby RS, Slavotinek A, et al. Pregnancy outcomes in patients exposed to OnabotulinumtoxinAtreatment: acumulative 29-year safety update. Neurology. 2023;101(2):e103-e113. doi:10.1212/WNL.0000000000207375
10. Wong HT, Khalil M, Ahmed F. OnabotulinumtoxinA for chronic migraine during pregnancy: a real world experience on 45 patients. J Headache Pain. 2020;21(1):129. doi:10.1186/s10194-020-01196-1
11. Peretz A, Stark-Inbar A, Harris D, et al. Safety of remote electrical neuromodulation for acute migraine treatment in pregnant women: a retrospective controlled survey-study. Headache. 2023;63(7):968-970. doi:10.1111/head.14586
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