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. 

Magnesium
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.  

Chiropractic Care
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.

Massage
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. 

MSG
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.

Fatigue
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.

Dehydration
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. 

Third Trimester

When I was pregnant with Chloë, I don't remember there being a specific day that I felt like the baby grew a couple of pounds. For some reason, the day I hit week 25 was like "oh, hello body, you must have a child in there." The tummy just felt very large, and I kept bumping it into things, and my lower back was achy in protest. Thus began the constant battle of trying the ease the constant back pain. I am so very thankful for my massage chair (basic as it may be, it does help a little), and for the back rubs (knot massages, really) that my sweet husband gives me.

Besides the back pain, I've really been doing great. I've had a couple of random bouts of morning sickness, and the occasional food aversion, but usually have a great appetite. Things like warm chocolate chip cookies and a tall glass of milk always sound good, and I actually manage to resist most days. I'm slowly and steadily gaining weight, which is good. I've had very little of the restless legs, have been sleeping pretty well most nights (credit due to the Unisom I'm still taking, I'm sure), and my complexion never completely freaked out like it did with Chloë. Shoelaces are suddenly hard to get to, and it sure isn't easy to lean over the side of the crib if I have to lower a sleeping toddler down. I seem to get minor braxton-hicks contractions every day, especially if I am on my feet a lot. So I try to do everything in spurts, since it helps the back pain, too.

I actually had another complex migraine last night (numb on one side, can't talk, blind... fun stuff), but was pretty well recovered by this morning. After talking to a couple of fellow migraine-suffers, and putting the pieces together, I decided to really be proactive about avoiding MSG. Monosodium Glutamate, an additive to many savory foods, has been a known migraine trigger for ages. I always knew I risked getting a migraine if I ate at a Chinese restaurant (always famous for using lots of MSG), and it just recently occurred to me that small amounts of the stuff may be giving me migraines. So after lots of research, clearing out my cupboards, swearing off favorite comfort foods like Cheese-Its, I think I finally figured out a big piece of my migraine puzzle. I didn't realize how often I was actually ingesting MSG, and have been astounded to learn that ingredient labels can legally hide it under other names... like yeast extract, or hydrolyzed protein, or fancy words like sodium calcinate, or even "natural flavors." Because, after all, MSG is natural. Some people's bodies just respond to it like neuro-poison. I've seen a drastic improvment in the frequency of my headaches. In fact, besides the complex migraine I had last night, I haven't had any migraines since I cut out MSG three weeks ago... except for the couple of times I ate something that I later learned had a form of MSG. Very interesting.


Week 20


Week 21


Week 24


Week 26

And now I'm at week 27. The third trimester. Just under three months until my due date... until we get to meet our little girl! Yes, this pregnancy has gone much faster. We're planning on doing another home birth, in case anyone is curious. As hard as it was the first time (is anyone surprised that I said that?), I loved being at home, and the midwives and my husband were great, and my body eventually figured out what it was doing. Maybe the second time will be (just a tiny bit?) easier.

Complex Migraine, round 2

Bryan and I were sitting on the couch last night, playing with Chloë. She threw herself against my right arm, and it only took me a second to realize what that awful feeling was. Numbness.

I grabbed my arm, felt up and down, and quickly assesed how much of my body was numb. Most of my arm... my upper chest and neck. I could feel the numbness creeping up face, and down into my finger tips. It was like a line had been drawn down the middle of my face: right side, numb, left side, normal. The feeling of numbness is similar to that when a hand or leg "falls asleep," before it starts to hurt, but a lot more intense. I slowly touched my face... my eyelid, nose, lips, tongue... the face is the the weirdest to have numb.

It takes 10 or 15 seconds for the realization to settle: I'm getting another complex migraine.

I don't get them very often. But when I do, I have a hard time not feeling like my body is being invaded by machines or aliens or someone else's synapses. My body just feels so overtaken and foreign. After the numbness slowly evolves and moves through one side of my body, I wonder what will come next. The inability to talk? The flashy lights in my head or the blackout of half of my vision? Or maybe the intense pain. Normally, I would have wasted no time getting some Imitrex and probably some Excedrine into my system. But no, not this time. This time, I need to keep Baby safe, and the angry nerves under my skull pose no risk to the baby growing in my belly. Medications, on the other hand... we just don't know, and so, we play it safe. (I had one of these fun migraines when I was a little further along in my pregnancy with Chloë, so the migraine and pregnancy combo wasn't anything new.)

Hemianopsia is just a fancy word for having one side of your vision gone. This is also an "evolving" symptom, sometimes starting with little flickers of light far off to the side. And then they get brighter and grow stronger, sometimes as white sparkles, sometimes as yellow lightning bolts, until they take over half of what I can see. Then at some point the flashing lights fade to a still gray or black, and then I am just basically blind on one side. I find myself a dark, quiet place to lie down, and try not to use my eyes. Simple tasks like texting become extremely difficult.

Expressive aphasia is the strangest of the little monsters. The migraine takes over the part of my brain that controls speech, and, if I choose to open my mouth, it would be easy for a listener to pick up on the short-circuits or random firings. And this is, hands down, the weirdest part of the whole experience. It is also the one thing I have some control over. "Even the foolish man is considered wise when he keeps silent." If I don't try to talk, my mouth can't misbehave. But as soon as I open my mouth, there is a foggy disconnect. Like I'm trying to think through a pillow. The feeling is similar to the one we get in the middle of a bad dream, when we're trying to run, but can't, or yell, but can't, or fly, but can't. Only this isn't a dream. It's my tongue. And it doesn't work. And I really, really don't like it.

When I mentioned the part about pain, I did actually say maybe. Strangely enough, there have been a few of these crazy headaches with little to no pain. But pain is the familiar part. Pain is like the horrible, predictable old friend. I've had a thousand migraines, and the pain is always the same. Stabbing, throbbing, pounding... the feeling that my head might spontaneously explode, and that pressing a knuckle or pillow into the part that hurts the most helps just a tiny bit. As much as I hate the pain, there is something strangely comforting about the familiarity. If it weren't for the familiar pain, I wouldn't be able to quickly rule out other awful things like having a stroke or growing a tumor. It's just a mean old nasty headache. And it will go away.

I was out of commission for last night and a good part of today, but have bounced back fairly quickly as far as migraines go. Maybe I'll post some cute videos and pictures in the next day or two.

Just a Complex Migraine

Shortly after B went to work this morning, I reached up to open the curtains and thought "whose hand is that?" And then it occurred to me that my vision was not normal. At all.

I immediately wondered if it was complex migraine-related despite the fact that my head did not hurt, and quickly made and consumed a double-shot espresso and went to lie down. But the vision just kept getting worse. There weren't any migraine-classic flashing or blinking lights, just lots of blind spots, making things like reading (or using my cell phone) almost impossible. I've had these sorts of migraines before, but at this point I wasn't having any of the other neurological symptoms, and was starting to get a little nervous since blurry or disturbed vision can be a scary thing during pregnancy. B wasn't answering his cell, so I got a message to him by texting one of his coworkers. I wasn't sure if the text said what I intended, but B quickly came home.

We were trying to decide if I should call my midwife, and then my left hand started tingling. I was strangely relieved. The numbness intensified, and the left side of my face (and nose and tongue) followed suit. And then the recognizable pain in the right side of my brain. I called my Dad (who just happens to be a doctor, and is quite familiar with my medical history) just to make sure I shouldn't freak out for the baby's sake. He said not to worry, "the migraine won't effect your uterus." I just needed to hear someone else say it.

Then I couldn't connect my brain with my mouth. Expressive aphasia. I wasn't using the weird word substitutions that I have in the past (B's favorite from a couple of years ago was when I said "macaroni" instead of "elbow"), but I couldn't really recognize my own voice, and it almost seemed like someone else was talking for me. That's when I just avoid talking. It's too weird to have such an out-of-body and out-of-mind experience. B tried offering some words of encouragement, and then I realized I wasn't really understanding what he was saying, either. Receptive aphasia. That's a complex-migraine first for me.

B made me some more coffee, bringing my caffeine intake up to four shots of espresso, and I noticed a marked increase in fetal movement. I told B it was okay to go back to work, and somehow fell asleep. I woke up a couple of hours later with some lingering blind spots and an ache in my head, but semi-functional, and relieved that what had just happened was no big deal for our baby. She just had a little taste of a caffeine buzz. Pregnancy crisis averted.

(My sister once blogged about a past experience I had with a complex migraine. She's such a great writer.)