Tuesday, April 29, 2014
Pregnancy and Migraines
Every couple of months, someone asks me for my advice on what I do for migraines during pregnancy. I finally decided to put everything in one place; hopefully nice and neat and not too long, boring, or confusing. So here goes.
I've suffered from migraine headaches for as long as I can remember. When I was in my early teens, they became a regular and frequent part of my life. I remember lying in bed all day in my dark bedroom, trying not to cry, because the stuffiness from crying just made the pain worse. Some of my grandparents, both of my parents, and all four of my siblings get migraines too. When a medication called Imitrex was invented, all of our lives experienced drastic relief from the plague of migraines.
Then I grew up, became a nurse, and got married. When my husband and I decided to start a family, I knew that Imitrex wasn't safe to take while pregnant, so I wasn't sure what I was going to do.
Understanding what a migraine actually is is helpful in understanding our treatment options. A migraine is defined as "a severe recurring headache, usually affecting only one side of the head, that is characterized by sharp, throbbing pain and is often accompanied by nausea, vomiting, sensitivity to light, and visual disturbances." The physiology of a migraine is complicated, but we know that it involves the blood vessels and nerves threaded through the brain. Blood vessels and nerves usually run right next to each other, and during a migraine, the blood vessels are dilated (expanded), and so they push on the nerves that they're next to. And nerves just don't like to be messed with, so they get all inflamed and cause a fuss. Meaning a horrible migraine. Understanding this concept is really helpful when trying to figure out what to do to make a migraine go away. Some medications, like Imitrex, can actually stop what's causing the migraine. It's complicated, but essentially, the medication helps to constrict (or narrow) the blood vessels in the brain, which means they stop pressing on the nerves they're next to. Basic "pain meds" just help block (or at least dull or turn down) the signal of pain, which is nice, but doesn't really fix the problem. Drugs like Tylenol and Advil don't help much (although NSAIDs like Advil usually help a little more than Tylenol because they have an anti-inflammatory component, which can help relieve some of the pain-causing pressure on the nerves). Stronger opioid prescription pain meds like Codeine or Hydrocodone (also referred to as narcotics) do a better job at blocking that pain signal. They basically numb or dull the sensation of pain. Which can be nice, but they don't actually solve the problem that is the migraine.
Unfortunately, we don't know much about how Imitrex (and other sumatriptans) affect a growing baby during pregnancy. It is classified as Pregnancy Category C (look at this if you aren't familiar with Pregnancy Categories), and research shows "in developmental toxicity studies in rats and rabbits, oral administration of sumatriptan to pregnant animals was associated with embryolethality, fetal abnormalities, and pup mortality," especially during the first half of pregnancy. That's enough information for me to steer clear of the stuff, especially during the first and second trimesters.
Now that I'm 3/4 of the way through my third pregnancy, I have experienced a lot of migraines during pregnancy. I've longed to take one of those little magic Imitrex pills, but in my opinion the risk just doesn't outweigh the benefit, even when the migraines are so bad that I'm awake all night throwing up.
Ways to Treat the Migraine
I usually find the best relief when I combine most of these tactics. When I feel a migraine coming on, I usually ask my husband to rub my neck, take Tylenol, drink coffee, sip Powerade, take a hot and cold shower, and rest. I usually get at least some relief, and sometimes I can actually get a migraine to go away.
Tylenol and Caffeine
Although Tylenol (Acetaminophen, also abbreviated APAP) is one of the few drugs considered safe to take during pregnancy (Pregnancy Category A), it should still be taken with caution. Taking more than four doses of extra strength Tylenol in 24 hours can cause liver damage. And if something is damaging your liver, it's probably not good for a developing baby. Caffeine has not been formally assigned a pregnancy category by the FDA, but there are warnings about using it during pregnancy, especially during the first trimester. Those warnings are usually about how caffeine is a vasoconstrictor, which means not as much blood is going through your blood vessels to your placenta, which means the baby is getting less of what he or she needs from you. But the vasoconstriction is exactly why caffeine can help migraines. It causes vasoconstriction (making the blood vessels in your brain shrink down), which relieves that horrible pressure on the nerves causing all the trouble. In fact, Excedrin Migraine is a medication that has Tylenol, caffeine, and Aspirin. I would just be tempted to pop a couple of Excedrins, but Aspirin is Pregnancy Category C, which I don't want to take.
So I take two Extra Strength generic Tylenol (1000mg total of Acetaminophen), and make a double or triple shot of espresso. Or sometimes I nudge my sweet husband in the middle of the night, and he lovingly gets out of bed to make me coffee: a triple shot espresso, with just a little sugar and cream to cool it down and make it palatable. If I'm nauseated from the migraine, it's really hard to actually drink (or smell) coffee, but room-temperature espresso is easier to stomach than hot. Since Tylenol by itself doesn't really help with migraine pain, you may wonder why I bother. Because caffeine is a stimulant, it can boost the effectiveness of pain killers by 40%. Which isn't magical, but every little bit helps.
The flip side of this fix is that caffeine actually makes migraines worse for the occasional person or particular headache. Especially if you're already dehydrated. Since caffeine is a diuretic, it can make you more dehydrated than you already are, which can make your migraine worse. Not good. Also, coffee contains small amounts of tannins, which is a compound that has been known to cause migraines. This is what I call a bummer. Or a catch-22.
Hot and Cold Shower
I've been using this treatment for years (even when I'm not pregnant), and it can really help. When I have a migraine, I have to drag myself to the shower. Then I get the water nice and hot, and let it blast the back of my head, neck, and shoulders for a couple of minutes. Then I turn it to cold. Not all the way, because I can't stand it, but almost. Then I let the cold water blast the back of my head, neck, and shoulders for about 30 seconds. Then I go back to the hot water for 30 seconds. Then back to the cold for 30 seconds. Back and forth for about five minutes: five hot cycles, and five cold cycles. A little longer, if I can stand it.
Basically, I'm messing with my blood vessels, trying to shock them into some state of normalcy. Now this sounds strange, but that's the best hypothesis I've got. Cold constricts blood vessels, and heat dilates them. For some reason this back and forth can help a migraine to go away. Not completely the second I step out of the shower, but I usually experience a good amount of relief, and sometimes within a half hour or so, my migraine is greatly improved.
Some research has shown that having low magnesium levels may be related to the occurrence of migraines. One small study showed that people who started taking 600 mg of magnesium a day reduced the frequency of their migraines by 41%.
Some data suggests that magnesium is difficult to absorb when your body is already raging with pregnancy hormones. (Vitamin D, Vitamin B6, Vitamin B12, and a little calcium are essential for magnesium absorption, so it's good to make sure you're getting those, too.) Even so, I'm not suggesting you start popping magnesium like candy. It can cause diarrhea. Lovely. And other problems. However, I did some research and decided to try topical absorption. Meaning, you put the stuff on your skin, and it absorbs into your bloodstream and goes where it needs to go, without upsetting the gastrointestinal tract. Some people use magnesium oil. However, it isn't actually oil at all; just water highly saturated with magnesium chloride salt. And it's pretty expensive. A friend said it's easy (and a lot cheaper) to make your own, so I bought a spray bottle and some magnesium bath flakes (which is magnesium choride salt!), and did just that.
I started using a little every day in the first trimester of this pregnancy, and had a drastic decrease in the number (and longevity) of my migraines. I'm a believer.
Also. Epsom salt actually has a lot of magnesium in it. So when I get a migraine, sometimes I pour about a cup of cheap Epsom salt into a bath, and soak for a good long while to let some of the magnesium absorb into my body. And of course relaxing the muscles in the neck and upper shoulders are good for relieving some of the pain.
I discovered that Powerade has magnesium, but Gatorade doesn't. From the labels I've read, most Powerades also have Brominated Vegetable Oil, sometimes called BVO, which is used as a flame retardant, and something I try to avoid putting in my body while pregnant. But, the "white cherry" flavor of Powerade doesn't have BVO. So I keep a few bottles of that in my pantry, and open one when I feel a migraine coming on. Maybe there's a larger electrolyte imbalance going on in my body, but sipping a Powerade has actually eased a few of my migraines. And even if it doesn't actively help, I figure hey, the extra electrolytes will be great if the migraines gets to point where I start throwing up.
Bonuses of taking magnesium: it can help with morning sickness, as well as restless leg syndrome. That's three times for the win!
Vitamin B2, also called Riboflavin
I need to add this supplement back into my life. I tried taking B2 regularly in high school, but didn't notice an improvement in my migraines, so I stopped. That was half my lifetime ago, and I'm sure my body and brain have changed a little since then. Another small study showed a 50% improvement in migraine occurrence when 400 mg of B2 was taken regularly. So it certainly might be worth trying.
I haven't actually tried this, but I have a couple of friends that will testify that regular neck adjustments almost cured them of their migraines. Part of the reason I haven't tried this option is simply financial. Our insurance won't help pay for such things, and seeing a chiropractor once or twice a week would get really expensive really fast.
A good massage to the neck and shoulders feels so good when I have a migraine. Again, visiting a masseuse isn't cheap. But my husband has been practicing on my neck and shoulders for eight years now, and even a ten minute massage can help. It doesn't exactly cure a migraine, but it does give me some pain relief. And if I can have him rub my neck and shoulders when I feel a migraine coming on, I think it has actually helped make it go away.
Perscription Pain Meds
This is where we really get into controversial territory, since narcotics are considered Pregnancy Category C. If used regularly, they jump over in the D category. Some medications are considered a little bit safer in the third trimester; once the baby is past the super development stages. Resorting to narcotics is something I did not do during my first two pregnancies. But at my appointment with my doctor two weeks ago, I was curious what she had to say about Imitrex and the third trimester. I wasn't surprised that she said she wasn't comfortable with it, but then we discussed how Codeine or Hydrocodone would probably be a better option-if used very occasionally. I thought about it, and decided I would be okay with that. I filled my prescription, and within the week, woke up throwing up with a dreaded migraine. Two days shy of 30 weeks gestation, I hesitantly took a codeine and a triple shot espresso. I was so happy when I could feel it numbing my pain, and I went from bedridden to functional (but still with some pain, and a little groggy). I understand that some people are not comfortable with this option, even in the third trimester, but you should do your own research and talk to your doctor about this one.
Triggers to Avoid
During my second pregnancy, I started figuring things out, and realized that there were some very specific things that triggered migraines during the hyperhormonal state of pregnancy. When I'm not pregnant, I can usually get away with small portions of these things. But when I'm pregnant, my brain is just more sensitive to these things, and I do my best to avoid them.
There are many other substances and circumstances that may contribute to migraines (extreme changes in temperature, bright or flickering lights, strong smells, etc.), but these are the biggest triggers for me.
The biggest trigger for me is monosodium glutamate. And not just MSG, but all of it's "cousins." I found a really helpful list that shows what other ingredients technically aren't MSG, but are similar enough that they act like it: they make food extra savory, and they give me migraines. Just because a package boasts "No MSG!" doesn't mean it doesn't have one of those other sneaky chemicals in it. After much experimenting, I've discovered that anything in the first column of that list will straight up give me a migraine when I'm pregnant. Which means that I read everything with a label. Sweet stuff is usually safe, since all of those chemicals are responsible for a savory food experience. So everything from chips and crackers to pre-prepared meats, sauces, and dips are possible migraine triggers. I realized so much of what I was eating had those horrible chemicals in them. Sausage, Papa Murphy's pizza, curly fries, cheese crackers, soup broth... the list of foods I don't eat right now is pretty long. But totally worth avoiding. It's a small blessing that there are still savory pre-packaged foods that I can eat. Plain potato chips or plain crackers are great. I can actually still eat a Papa Murphy's pizza, as long as it has the marinara sauce (and not the garlic alfredo sauce), and none of the meats. After I adjusted my food intake during my second pregnancy, I went from having migraines constantly to almost never. It was amazing.
Wine. Meaning sulfites, tannins, and tyramines.
Our church serves real wine every Sunday for communion. And while I have nothing against the occasional sip of wine during pregnancy, I avoid the stuff like it's toxic. Just that one sip of wine is enough to give me a migraine. This is a good article that explains what is really going on with wine and migraines. For me, I think it's the combination of the chemical makeup of the wine. Because lots of other foods contain sulfites, tannins, and tyramines, and they usually aren't a problem. But all together in wine? Nope. I have noticed the occasional migraine from over-indulging in dark chocolate (which has tannins), so I'm careful about not eating too much at once.
Being pregnant, avoiding fatigue is easier said than done. Especially in that first trimester. But when I try to do too much, and skimp on sleep, I almost always get a migraine. Especially if I do too much and skimp on sleep for two or three days in a row. No good. Even now that I have two kids, I prioritize rest and sleep. I don't stay up late getting projects done or watching TV. I sleep. A rested mommy is usually a migraine-free mommy.
I think this goes without saying, but stay hydrated. If you're doing a lot of sweating (or throwing up, or anything else that uses up electrolytes), make sure you're replenishing those too. You can actually swing the other direction and have enough water but not enough sodium, potassium, calcium and magnesium, and put your body in a state similar to overhydration (also called water intoxication). Coconut water is a great natural source of electrolytes. White cherry Powerade also gets my vote. I've also been known to drink pickle juice (which has tons of sodium) after a day in the sun.
As a nurse and life-long migraine sufferer at the end of my third pregnancy, these are my experiences. I'm sure there are some conflicting testimonies out there, but if you have any tips to add (or corrections on facts), feel free to leave a comment! And as always, talk to your health care provider about this stuff.