Clinical Inquiries. What are the best therapies for acute migraine in pregnancy?

■ Evidence summary Eighteen percent of all women report migraines. As estrogen levels increase early in pregnancy, many women report an increase in headache or new-onset headache. As estrogen levels stabilize in the second and third trimester, 60% to 70% of women with migraine report reduction in symptoms. Nonpharmacologic treatment. A small case series of electromyograph (EMG) biofeedback and relaxation techniques on 5 pregnant women showed that 4 became headache-free. It is impossible to say whether it was the intervention, natural disease progression, or the attention received from the therapist that produced this result. Two studies were published together evaluating thermal biofeedback, relaxation training, and physical therapy exercises. The first, a cohort study, showed decrease in symptoms for 15 of 19 women. The second, a small randomized controlled trial, compared 11 women using the combination treatment with 14 control women who received attention from the therapist but no other intervention. More than 72% of the treatment arm improved, compared with nearly 29% of the attention control group. Interpretation of these studies is limited by small sample size and testing in settings with specialized resources that are not found in every community. Sumatriptan and other agents. Six It is helpful to test nonpharmacologic treatments during the prepregnancy period For young women diagnosed with migraine, begin discussing with them during the family planning period treatment options for acute migraine in pregnancy. Trials of approved medications and nonpharmacologic treatments can be given at this time to evaluate their efficacy and to give the patient time to feel comfortable with them. It is especially important to test nonpharmacologic treatments during the prepregnancy period. In my own experience as a physician, and as a young woman with a long-standing history of migraine, biofeedback and relaxation techniques work better when the patient is first exposed during pain-free or subacute pain periods. For moderate to severe migraineurs, it is difficult to institute these techniques during a full-blown attack. For such patients, experience with safer treatment modalities before pregnancy would allow greater success for treatment of acute migraine during pregnancy.