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Expert commentary

by Rebecca Burch, MD, FAHS

Migraine is highly prevalent in the generally population, but the most highly affected demographic is females of reproductive age. Available evidence suggests that between 20-30% of females between 16 and 45 years of age experience migraine each year. Physicians often think about the possibility of pregnancy in the setting of medication safety and the need to avoid medications with high pregnancy safety risk. Most physicians are aware that migraine often improves over the course of pregnancy and that treatments with evidence for safety in pregnancy are available.

According to this study by Dr. Ishii and colleagues, our patients may not have the same understanding of the effect of migraine on pregnancy. This study of adult women enrolled in the American Registry for Migraine Research (ARMR) found that about 20% of participants altered their pregnancy plans due to migraine. The group of participants who altered their pregnancy plans were younger, had fewer children, and had more frequent and disabling migraines. 73% of this group felt that that migraines would make pregnancy very challenging and 68% believed that migraine would worsen during pregnancy. The American Registry for Migraine Research enrolls participants from headache specialty clinics, and this is therefore the first study to show what patients seen in typical headache clinics believe about the effect of migraine on pregnancy. The prevalence of altered decision making related to misconceptions about migraine in pregnancy is likely to be surprising to many physicians. In future studies, it will be interesting to know the beliefs about migraine and pregnancy in patients who have not changed their reproductive plans.

Although most providers are happy to answer questions about migraine and pregnancy, many wait until the patient raises the topic. The findings from this study suggest that a more proactive approach may be helpful. At the same time, assumptions about the desire for future pregnancy should be avoided. The findings from this study may provide a neutral opening. For example, a statement such as “I recently read a study showing that patients with migraine may be concerned about pregnancy or having children because of their migraines. Is that something you’ve thought about, and are there any questions I can answer?”

Although not specifically discussed in this paper, these findings also inform the approach to treatment planning for migraine during pregnancy. The relative lack of data about medication pregnancy safety sometimes leads to an approach of avoiding or minimizing medication use. For patients who have significant concerns about how pregnancy will affect migraine control, a more aggressive treatment approach may be appropriate. This study thus also supports the need for more research into migraine medication safety during pregnancy. As more safety information becomes available, we are better able to reassure patients that there are many good treatment options.