Woman & hormones

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Pregnancy is a carefree and pain-free time for most women. Studies have shown that almost 70 percent of affected patients experience a significant improvement or even a complete disappearance of migraines during pregnancy. This effect is particularly noticeable in the last two trimesters. Whether this positive effect on migraines gradually diminishes with subsequent pregnancies is currently unclear. After delivery, nearly half of the patients complain of a recurrence of headaches in the first week, predominantly tension headaches, but also migraines.

The reason for the sometimes spectacular improvement in migraines during pregnancy remains completely unclear. However, various hypotheses are being discussed. One theory is that the increased concentrations of estrogen and progesterone, and their constant levels during pregnancy, are the basis for this improvement.

Other explanations suggest that altered serotonin metabolism during pregnancy, as well as increased concentrations of endogenous opioids (endorphins), are responsible for the improvement. However, the altered lifestyle during pregnancy appears to play a crucial role: pregnant women generally eat more consciously, maintain a regular sleep-wake cycle, avoid alcohol and nicotine, try to live less stressful lives, and are less stressed in their work.

Treatment during pregnancy

Generally speaking, medication should be avoided during pregnancy whenever possible. This is especially true for prophylactic measures that require daily medication. These medications (beta-blockers, flunarizine, and serotonin antagonists) must not be taken during pregnancy. This is particularly important if pregnancy is planned or even just a possibility. Since young women often use such medications for severe migraines, doctors must advise them of the necessity of reliable contraception. As with any migraine, behavioral measures such as relaxation exercises and avoiding triggers are the primary recommendations for preventing migraine attacks.

Drug prophylaxis?

In cases of extremely severe migraines during pregnancy – especially migraines with aura – magnesium should be considered for prevention. While the overall effect of magnesium on the course of migraines was rather small in clinical studies, it was exceptionally impressive in individual cases.

For the treatment of arterial hypertension during pregnancy, doctors generally prescribe propranolol – a medication also successfully used for migraine prophylaxis. No harmful effects on the fetus have been observed. Nevertheless, propranolol should be used very cautiously for migraine prophylaxis during pregnancy and only considered as a last resort.

Acute therapy

There is very little literature on the efficacy and tolerability of medications for treating migraine attacks during pregnancy, with regard to childbirth and breastfeeding. Paracetamol was previously considered the safest pain reliever during pregnancy. Based on earlier data, its safety seemed beyond doubt. Pregnant women were advised to take this pain reliever with virtually no concerns for pain during pregnancy.

However, current studies necessitate a careful reassessment of this recommendation. Paracetamol use by pregnant women and subsequent exposure of the unborn child to the drug appear to significantly increase the risk of developing asthma and respiratory illnesses, as well as potential infertility in boys. Globally, there has been a marked increase in the prevalence of asthma in recent years. Paracetamol is the most frequently used pain reliever in Germany and ranks first among the most commonly prescribed medications. Simultaneously, the prevalence of asthma in the population has risen significantly in recent years. Paracetamol can lead to a reduction in glutathione levels in the lungs. Glutathione is believed to play a crucial role in the development of asthma.

Of particular concern is the well-founded suspicion of a significantly increased risk of developing cryptorchidism (undescended testicles) in boys. In affected individuals, this can later lead to reduced fertility and an increased risk of developing malignant testicular tumors. Sperm count and sperm viability may be reduced later in life. The combined use of two painkillers in pregnant women was associated with a sevenfold increased rate of cryptorchidism in newborn boys. It is suspected that the effects of a single 500 mg paracetamol tablet on the unborn child could be more harmful than the ten most common environmental pollutants. Paracetamol, in therapeutic doses, has so far been considered a safe, harmless, well-tolerated, and inexpensive painkiller. The risk that overdoses exceeding 150 mg per kg of body weight can cause irreversible liver cell damage leading to liver failure has already resulted in limitations on package sizes for self-medication.

The new studies have prompted a significant rethink regarding the use of painkillers during possible, planned, or existing pregnancies. Generally, painkillers should be avoided during pregnancy and breastfeeding. In individual cases of particularly severe pain, acute medication may be considered after consulting a doctor. However, it must be taken into account that so-called simple painkillers, such as paracetamol, only have a partial and short-term effect on severe pain attacks, while simultaneously posing lasting lifelong risks of complications for the unborn child. The studies have been criticized for not definitively proving a causal link. Until the exact relationship is clarified, however, the principle must be: when in doubt, prioritize the unborn child and avoid taking paracetamol, especially in combination with other painkillers. Based on the new data, the short-term benefits and long-term lifelong risks are not balanced in the case of possible or existing pregnancies. Contrary to previous recommendations, the use of paracetamol, both as a single-ingredient product and especially in combination preparations, is therefore discouraged during possible or existing pregnancies.

Ergotamines such as ergotamine tartrate and dihydroergotamine must never be taken. These substances cause uterine spasms during pregnancy. Furthermore, ergotamine has been shown to be harmful to embryos.

There is currently insufficient data on the use of triptans during pregnancy. While there are reports of pregnancies occurring during sumatriptan therapy without any apparent problems, triptans should not be used during pregnancy or breastfeeding until sufficient experience is available.

Details on drug-based attack therapy and drug-based prevention can be found in the Pregnancy submenu.

Birth control pill as a trigger?

The birth control pill is often blamed for persistent and difficult-to-treat migraine attacks. However, a closer look at the facts reveals no clear link in "watertight" (double-blind and placebo-controlled) studies.

The recurrence of migraine attacks in connection with taking the birth control pill is also a recurring topic of discussion. Since migraines are particularly common in the second decade of life – precisely the time when birth control pills are usually first started – there is at least a statistical correlation. However, whether this is a causal relationship is currently unclear.

New studies have shown that the risk of stroke is increased by a factor of two to three in people with migraines. Since the birth control pill further increases this risk—especially in combination with smoking—a neurological examination should be performed as soon as possible if neurological symptoms (e.g., dizziness, paralysis, speech difficulties, etc.) suddenly occur. This also applies to unexpected headache attacks, which can even occur daily.

Menopause and migraines

It is often believed that migraines gradually "burn out" in old age, meaning they decrease in frequency and intensity. However, studies show that in more than 50 percent of those affected, no change in their migraine pattern can be observed during and after menopause. In fact, about 47 percent of female patients even experience a worsening of their condition.

Even today, some patients with severe migraine attacks are subjected to a hysterectomy or oophorectomy as migraine prophylaxis. However, this has demonstrably no effect on the course of a migraine. Hormone therapies in later life also have no effect on migraines. Therefore, in this situation as well, migraine therapy should be carried out as usual.