Migraine during pregnancy

Women with migraine may experience migraine attacks more frequently in the first 3 months of their pregnancy due to hormonal changes that occur during the normal course of pregnancy. They experience fewer headaches in the second and third trimesters. This is because after the first 3 months, migraine attacks decrease due to reasons such as estrogen levels becoming stable, increasing endorphin levels, blood glucose metabolism becoming more regular, and muscle relaxation. All headaches experienced during pregnancy and breastfeeding should be taken seriously and should definitely be evaluated by a neurologist. Not all of these pains may be migraines and may be caused by an important underlying condition.

Especially the first headache or migraine attack experienced during pregnancy is a very important and important type of pain that should be paid attention to. The changing metabolism with pregnancy, changes in vascular circulation and hormonal status can trigger a number of serious diseases that can cause headaches. Unresponsiveness to treatment in migraine headaches during pregnancy requires investigating secondary causes. Of these, it is necessary to consider conditions such as preeclampsia and eclampsia, as well as diseases that can lead to thrombosis in the cerebral veins and threaten the life of the mother and the baby. In 10% of cases, the first migraine attack occurs during pregnancy.

Migraine attacks, which generally decrease in the last 6 months of pregnancy, may return with increasing frequency after birth due to reasons such as a sudden decrease in estrogen levels, changes in sleep patterns, and deterioration in quality of life. In addition, starting breastfeeding during this period may reduce the number of treatment options.

Therefore, in the treatment of migraine attacks that occur in the period immediately after pregnancy, it is necessary to take measures that increase the quality of life first and to be careful about sleep, nutrition, and migraine triggers. The possibility of simple painkillers and migraine-specific painkillers to be taken during headache attacks passing into the milk should be considered. For these reasons, milk should be expressed according to the time the drugs pass into the milk. In addition, the possibility of the passage of preventive treatments used in the classical sense into the milk should not be forgotten.

How is migraine pain treated during pregnancy?

Pregnancy plans should definitely be discussed with patients and the treatment they are receiving should be planned to be discontinued accordingly. If there is a pregnancy plan, the drugs that are dangerous to use during pregnancy should be reduced and discontinued according to a certain plan, and the treatment should be continued with the safest methods with strategies to be determined according to the patient’s condition. Attention should be paid to the risk groups of the drugs used here. In addition, sleep disorders, eating habits and other triggers that may increase migraine attacks should be determined. Since many drugs used in migraine treatment are not safe to use during pregnancy, it is the most rational approach for women with migraine who are planning a pregnancy to consult a neurologist before getting pregnant. Options for the treatment of migraine pain during pregnancy are limited. The best option is to carry out the treatment process together with your physician. Again, staying away from possible triggers, relaxation exercises, some biofeedback methods, meditation, yoga and maintaining regular healthy living habits form the basis of the pain method. However, despite these, some treatments can be recommended for pregnant women with migraine who have pain.

These;

Magnesium

The FDA has a safety category of D for pregnancy. In other words, its safety should be decided by considering the benefits it will provide to the patient.

Ondansetron

It is frequently used to prevent nausea and vomiting during pregnancy. It is pregnancy category B, and care should be taken when using it.

Metclopramide

It is used to treat nausea and vomiting during pregnancy. It is pregnancy category B. Central nervous system side effects should be taken into consideration.

Butalbital

This barbiturate derivative used in the treatment of headaches together with acetaminophen, aspirin, caffeine and codeine is prescribed quite frequently.

Paracetamol

It is a pregnancy category B drug used by most patients with pregnancy migraine. There is data that it may be associated with attention deficit hyperactivity in children.

Peripheral nerve blockade

It is a very reliable treatment method used for pregnancy migraine. It can usually be used comfortably after the 15th week of pregnancy and is quite effective.

Catamagnetic/Menstrual migraine

Menstrual migraine is more severe than migraine attacks seen in other periods and is also more resistant to treatment. The menstrual period is an important trigger, especially for migraines without aura. Due to hormonal changes, it occurs most frequently two days before menstruation and on the first day of menstruation. Correctly diagnosing menstrual migraine is important for determining the treatment strategy. In order to call migraine attacks related to menstruation, there must be migraine attacks without aura in at least two of the three menstrual periods, 2 days before and 3 days after menstruation. For this purpose, a headache diary should be kept for at least 3 months, the relationship between migraine attacks and menstruation should be clearly determined and the treatment strategy should be planned accordingly.

TREATMENT OF MENSTRUATION MIGRAINE

Non-drug Measures

In menstrual migraine, as in other migraine attacks, it is necessary to take measures to reduce attacks. It is necessary to pay attention to sleep patterns, stay away from foods that trigger migraine attacks and alcohol consumption, and avoid bright lights and strong odors. It is especially necessary to be careful about birth control drugs and hormone use.

Attack Treatment

Similar drugs are used for migraine attacks that occur during menstruation. Simple painkillers or migraine-specific painkillers (triptans) used during this period should be taken as soon as possible after the attack starts, depending on the severity of the attack.

These are treatments that are started 2 days before the menstrual period and continued for the first 3 days of the menstrual period. Since the start date of menstruation is important in this treatment plan, it can only be considered in women with regular menstrual periods. In cases of irregular menstrual periods, the date of starting the medication can be determined by measuring daily body temperature. While drugs used in migraine attack treatment can be used, drugs in the form of skin patches and gels can be used to control estrogen fluctuations.

Long-Term Preventive Treatment

In the long-term preventive treatment of menstrual migraine, hormone treatments can be used in addition to the classical drugs used for the preventive treatment of migraine. For this purpose, drugs containing estrogen in different doses, which can be applied orally or through the skin, can be used. Although less frequent, intrauterine progesterone applications can also be preferred. The aim of continuous hormonal treatment is to suppress the activity of the eggs and create a regular hormonal balance. However, it should not be forgotten that hormone treatment increases the risk of cerebrovascular disease, especially in those with migraine with aura, smokers, older people and those with risk factors.

Migraine in the perimenopausal period

The perimenopausal period is a period when there is a risk of migraine attacks becoming more frequent, along with many complications due to irregular menstrual periods. Vasomotor symptoms that can be observed during this period can be prevented with hormone replacement therapy. Oral estrogen preparations can trigger migraine attacks, therefore non-oral treatments are recommended for these symptoms. Intrauterine levonorgestrel may be a treatment option. In women in whom estrogen use is contraindicated, paroxetine 7.5 mg (at night) or gabapentin can be used to prevent vasomotor symptoms.

Migraine in the Elderly

Primary headaches decrease with age, and secondary headaches should be excluded in differential diagnosis. Very rarely, migraine headaches may occur after the age of 50. A distinction should be made between aura and transient ischemic attacks. Ergotamine and triptans should be avoided in patients with these symptoms or in patients at risk of ischemic attacks. Since the possibility of comorbidity is high in this age group, this situation should be taken into consideration in attack treatment and preventive treatment. Paracetamol, NSAI, combined analgesics, antiemetic agents, IV magnesium sulfate (2 gr, given over 10 minutes) can be used in attack treatment. Beta blockers, calcium channel blockers, antiepileptics, antidepressants can be used in preventive treatment.

Status Migraine

Status migraine is the attack lasting longer than 72 hours. The most important difference from chronic migraine is the duration (it is not a pain that lasts for 3 months like chronic migraine), the severity of the pain and accompanying symptoms. Secondary causes must be ruled out. Some patients need to be hospitalized and treated.

Childhood Migraine

The prevalence of migraine in children is around 10% for girls and 5% for boys. Childhood migraine headaches do not have typical features like those in adults. Children under the age of 12 may have difficulty defining their headaches, and typical symptoms such as photophobia and phonophobia, which are included in the diagnostic criteria, may not be seen, so we can see migraine-type headaches that do not meet the diagnostic criteria in around 10% and headaches that can be called possible migraines in around 45% of children. Another reason that makes diagnosis difficult is that attacks in the form of migraine variants can be seen in children. We should treat migraine attacks that can affect school success, school life, and quality of life after ruling out secondary causes.

Treatment is divided into two as drug and non-drug treatment. Non-drug methods should be tried first in children.

In non-drug treatment;
It is necessary to inform the child and the family about the disease,
Regulating the lifestyle; especially regulation of sleep and nutrition, regular exercise, relaxation techniques and increasing awareness of triggers and ensuring avoidance of them
Rest and sleep in a dark and quiet room when an attack occurs Behavioral therapies; relaxation exercises, biofeedback

Drug treatment is divided into two as attack and preventive treatment.
A number of drugs suitable for age groups are used in acute attacks. Preventive, or prophylactic treatment, can be applied especially to children who prevent daily life activities, create anxiety, and have headaches more than 3-4 days a month. Prophylactic treatment has similar characteristics to those in adults. Side effect profiles and additional disease conditions should be evaluated well in drug selection, and drugs with excessive sleep effects should be avoided, especially in school-age children.

Migraine Treatment in Adolescents
Migraine headaches increase especially in girls during adolescence due to the effect of sex hormones. While it is seen at a frequency of 10% in girls under the age of 12, this rate increases to 18% between the ages of 12-14. In order to determine the relationship between migraine attacks and the menstrual cycle, a headache diary should be kept by the patient for at least two months and a decision should be made and treatment should be started accordingly. All drugs used in adults can be used in acute attacks and treatment.

Neuromodulation is the concept of stimulating and reorganizing nerve tissues that cause neurological diseases, have lost function, or cause various clinical symptoms due to dysfunction, through chemical or electrical applications. Providing stimulation in nerve tissues that have lost function can partially restore the missing function of this nerve tissue. With this method, abnormal stimuli and/or pain caused by nerve tissue can be suppressed with neuromodulation and the patient’s complaints can be reduced.

How does neuromodulation show its effect?

In nerve tissues that have suffered functional loss, a number of neurochemical substances are released and various abnormal electrical activities occur through these neurochemical substances. In a healthy nerve tissue, the nerve continues its physiological function with the type and help of these neurochemicals. Due to the damage to the nerve tissue and the functional loss that occurs as a result, physiological electrical activity may not be provided. In this respect, the electrical and chemical stimulation given to the patient from outside with neuromodulation provides the reorganization of these mechanisms.

For this stimulation, batteries that can generate electricity from outside or pumps that inject drugs help. These batteries used for neuromodulation are applied by placing electrodes into the tissue in a way that fits the nerve tissues in the brain, spinal cord or body areas close to these regions. These electrodes produce electrical impulses with an appropriate intensity to stimulate the targeted tissues. Problems related to many different neurological diseases such as Parkinson’s disease, essential tremor (tremor disease) and migraine can be solved with these methods.

What are the diseases in which neuromodulation is used?

Neuromodulation can be used in the treatment of any neurological disease that causes deterioration in the functions of nerve cells. Since neuromodulation equipment must be placed inside the body with interventional methods in patients and it is an expensive method, its application is usually brought to the agenda in clinical cases that are resistant to drug treatment, not suitable for surgical treatment and accompanied by severe clinical symptoms.

The most common disorders in which neuromodulation is used in clinical applications are epilepsy, migraine, chronic nerve-related pain, Parkinson’s disease, urinary incontinence and hearing loss. Neuromodulation treatment methods that are successfully applied today can be listed as follows:

• Spinal cord stimulation (spinal cord pacemaker)
• Posterior root ganglion stimulation
• Sacral nerve root stimulation (bladder pacemaker)
• Chronic pain neuromodulation
• Peripheral nerve stimulation
• Deep brain stimulation (brain pacemaker)
• Intrathecal drug infusion (baclofen pump)
• Vagal nerve stimulation (epilepsy pacemaker)
• Transcutaneous electrical nerve stimulation
• Transcranial magnetic stimulation
• Cochlear nerve stimulation
• Visual prosthesis

What are the concepts of neuromodulation and neurostimulation in migraine treatment?

Neuromodulation (NM) and neurostimulation (NS) have an important place among non-drug treatment options for migraine. Classic drug treatments are the first line in migraine treatment. The answer to the question of which migraine patients are subject to non-drug treatments is;

Patients whose attacks continue despite receiving appropriate drug treatment,

Patients who experience side effects due to the drugs used,

Patients who have interactions between drugs used for migraine treatment due to another disease,

Patients who have another medical condition that prevents them from taking appropriate drugs.

NM and NS have become important methods among non-drug treatment options for migraine.

How do neuromodulation and neurostimulation affect migraine?

The neurostimulation method can be briefly defined as the stimulation of loss of function or abnormal neurochemical response in the nerves associated with headache by means of an electrical current, magnetic current or direct current with the help of specially developed devices.

NS in migraine can be performed on the skin around the head, or with special devices placed invasively near the nerves that cause headaches.

Non-invasive methods applied on the skin around the head;

Supraorbital Transcutaneous Stimulation (STS)

Transcranial Magnetic Stimulation (TMS)

Transcranial Pulse Stimulation (TPS)

Transcranial Direct Current Stimulation (TDAU)

Vagal Nerve Stimulation (VSS)

Each of these methods may not be suitable for every migraine patient. Therefore, it should be determined which of these methods will be used selectively for patients whose appropriate indications have been determined by a neurologist.

Supraorbital Transcutaneous Stimulation (STS)

Cefaly

It is applied to the supraorbital nerve, which is also used for nerve blockade. It originates anatomically from the eye socket and is known to be associated with headaches. The device is attached to the head like a band or crown and provides electrical stimulation to the supraorbital nerve with certain frequencies.

The application practice is in the form of 20-minute stimulations per day for 3 months.

The first STS device approved by the American Food and Drug Administration (FDA) for chronic migraine was offered to patients under the name Cefaly᷿®. This device for chronic migraine was approved for prescription only, but later it was approved for over-the-counter sales.

This wearable migraine device has been updated as Cefaly Dual with the latest technological innovations and was approved by the FDA in 2020 for the acute (attack period) and preventive treatment of migraine headaches in adults aged 18 and over.

The device (Cefaly Dual) has 2 settings; ACUTE and PREVENT

In the ACUTE setting, the device is used for 60 minutes of pain relief at the beginning or during a migraine attack.

The PREVENT setting reduces the frequency and intensity of migraine symptoms in 20-minute sessions per day. The device automatically turns off at the end of each session.

Relivion MG

Another e-TNS device is Relivion. Unlike Cefaly, this latest noninvasive device delivers electrical stimulation to both the trigeminal nerve branches and the occipital nerve branches (stimulating a total of 6 nerve branches). It has two sensors placed on either side of the nose. It was approved by the FDA in 2021 for the treatment of acute migraine in adults. It is in the device group that requires a doctor’s prescription.

Transcranial Magnetic Stimulation (TMS)

As its name suggests, it is a device that shows its effect by giving magnetic stimulation to certain brain regions. This device, which is more known among migraine patients, is thought to affect the release of certain neurochemicals by giving magnetic stimulation from the back of the head, known as the occipital region, with the help of an apparatus that we can call a stimulator, by affecting the electrical fields in the cerebral cortex. It is thought to achieve this effect by affecting the polarization in the nerve tissue.

The TMS device was approved by the FDA in 2013 for migraine patients aged 18 and over, only for migraine attacks with aura.

Having metal in the head, neck or upper body, having an active implanted medical device (pacemaker, deep brain stimulator etc.), having a diagnosis of epilepsy, having a history of seizures in the family or in oneself are contraindications for TMS.

As a rule, it should not be applied more than once in 24 hours.

Single-pulse TMS (sTMS)

A potential preventive and acute treatment for migraines, sTMS can be applied at home by placing and activating a device behind your head. The device delivers a short magnetic pulse (the length is preset by your doctor) that targets the layers of the scalp, skull, meninges (membranes surrounding the brain and spinal cord), cerebrospinal fluid, and superficial layers of the cortex, where it modulates the electrical environment of neurons involved in migraine attacks.

In a study published in the journal Cephalalgia in May 2018, sTMS reduced the number of days people with migraines experienced symptoms. Users also needed less rescue medication.

The eNeura sTMS mini is an FDA-approved sTMS device, previously sold under the brand name Spring TMS. Battery-powered and handheld, it can be used for both prevention and treatment of migraine attacks.

The user places and holds the sTMS mini firmly against the back of the head to locate the base of the skull. With the push of a button, the device’s specially shaped electrical coils send a magnetic pulse designed to treat migraine attacks and prevent them by interrupting the abnormal electrical activity in the brain that is associated with them.

You need a doctor’s prescription to use the sTMS mini.

Transcranial Pulse Stimulation

The device on the market under the name Neurolith® has a mechanotransduction mechanism. Although it is mainly used for Alzheimer’s disease (by increasing growth factors, VEGF, cerebral blood flow, new vessel formation, nerve regeneration and nitric oxide release), studies are also ongoing for the treatment of migraine.

Vagal Nerve Stimulation (VSS)

Noninvasive VSS is thought to be effective in the treatment and prevention of migraine and cluster headache with the help of special devices such as the gammaCore® (electroCore) device. After being approved for the acute attack period of migraine in 2015, it was also licensed for the treatment of cluster headache in 2019.

The device has also been licensed for the acute and preventive treatment of migraine and cluster headaches for ages 12-17 as of February 2021. The device, which is the size of a computer mouse, applies a lubricating gel to the two stimulation points and then electrically stimulates the patient under the jawline, from any neck area for approximately 2 minutes. The intensity of the stimulation can be adjusted by the patient themselves. Regular use twice a day is recommended as a preventive treatment (for 3 months). It is the only NS device that has been approved for the treatment of hemicrania continua and paroxysmal hemicrania. A doctor’s prescription is required.

REN/Remote Electrical Neuromodulation

Remote electrical neuromodulation (REN) may be particularly useful for people with migraines who are concerned that using devices that apply electrical stimulation to the head may worsen the pain associated with attacks. Uniquely, this approach is designed to stimulate peripheral nerves in the upper arm. It is thought to reduce migraine pain by modulating a deep part of the nervous system involved in pain control. Specifically, REN activates pain control centers in the brainstem (the connection between the brain and spinal cord), which in turn blocks the pain signal that occurs in migraines.

Nerivio

Nerivio is a wireless remote neuromodulation armband that is FDA-approved for the acute treatment of migraine with or without aura in people ages 12 and older. The device is controlled by an app designed to provide personalized treatments.

The app includes a migraine diary that allows you to track treatment sessions and migraine attacks. You can share the diary with your doctor to help guide your migraine management.

Nerivio is available only with a doctor’s prescription.

Each Nerivio device provides twelve 45-minute treatments. After 12 treatments, the battery no longer works and the device must be recycled.

Implantable Occipital Nerve Stimulation

Implantable occipital nerve stimulation involves surgically implanting a device that sends electrical pulses to the occipital nerve, which is located at the back of the head, just above the neck. It is primarily used for chronic migraine patients who have failed other treatments.

A study published in the December 2020 issue of the journal Pain and Therapy found that the approach was effective for about 50 percent of people with chronic migraines who had an ONS device implanted.

ONS, in particular, differs from other nerve stimulation systems in that it involves surgery, but the procedure is reversible.

An implantable device under development by Salvia Bioelectronics uses mild electrical impulses to affect nerve activity, or the pattern of electrical impulses transmitted through the nerve fibers that control how your body works. The Dutch company is working on thin implantable bioelectronic foils that conform to the shape of your head to provide neurostimulation.

Specifically, the company’s implantable neurostimulation system (similar to a pacemaker) will be designed to use bioelectronic foil technology to disrupt brain processes that cause migraine attacks in people who have failed drug therapy. In 2020, the FDA granted Salvia a breakthrough device designation for its implantable technology.

1. GammaCore
2. NERİVİO
3. CEFALY DUAL
4. eNeura S-TMS mini
5. RELİVİON

 

In cases of Migraine, Cluster, Trigeminal Neuralgia and Tension Type Headaches, in cases resistant to drug treatment or in cases where drug treatment cannot be used (pregnancy etc.), nerve blockade methods can be used.

What is referred to as nerve blockade is based on the principle of administering a number of drugs (lidocaine, bupivacaine, triamcinolone, physiological serum etc.) to the nerves that cause pain attacks and are thought to be connected to the pain centers in the brain (Trigeminovascular and trigeminocervical system) using special injection techniques. Nerve blocks are interventional procedures.

Blockade can be applied to many nerves associated with head and facial pain (greater occipital nerve, lesser occipital nerve, supraorbital nerve, infraorbital nerve, supratrochlear nerve, auriculotemporal nerve, mental nerve etc.). More than one nerve can be blocked at the same time.

The most common is the greater occipital nerve blockade (GON = Greater Occipital Nerve). This nerve is directly related to the Trigeminovascular/Trigeminocervical system.

GON blockade:

Although its popularity has increased in recent years, its application history dates back to the 1940s. It can be applied as both an attack and a preventive treatment for migraine headaches. It is an effective and safe method for the treatment of migraine patients who are resistant to drug treatment or who cannot use medication due to various reasons such as pregnancy.

How is it applied?

Drugs applied to the greater occipital nerve with a special technique, sometimes (not necessarily) with ultrasound guidance, at neuroanatomically determined points, block the reversible sodium channels in the nerve fibers. Thus, the formation of pain stimuli in the nerve and vascular centers to which the nerve is connected, especially in the Trigeminocervical systems, and which are related to migraine headaches, is prevented. This effect also has a REGULATORY effect on the mechanisms that create migraine pain, which we call NEUROMODULATION.

The nerve, whose neuroanatomical localization is made with a special injection technique, is blocked by injecting a mixture of local anesthesia and physiological serum.

The injection can be made unilaterally or bilaterally.

Since local anesthesia is applied, there may be temporary numbness, matting or loss of sensation in the applied area.

How long is the application?

The procedure is completed within 1-2 minutes after the preparations are completed.

It can be applied weekly for 4-6 weeks. Afterwards, the application is continued monthly.

Since it is not only an attack treatment but also a preventive treatment, the application should be repeated at the times determined by the neurologist.

Does it have any side effects?

Although it is a very reliable method, some rare side effects can be seen.

As with all injection methods, infection at the injection site (if the area is not cleaned sufficiently), subcutaneous bleeding, secondary syncope/fainting or fainting due to injection, low blood pressure, nausea, palpitations may occur.

Local anesthetics can rarely cause heart rhythm disorders, allergic reactions and hypersensitivity reactions. Therefore, it is recommended to apply in a clinical environment.

In cases where steroids are applied, thinning of the scalp and hair loss may be observed in the application area.

Indications are primarily MIGRAINE type resistant headaches;

Occipital neuralgia

Cervicogenic headache

Cluster headache

Headaches due to muscle spasm

Diseases seen in intra-segmental structures

Regional cancer pain

In neural therapy applications, for interference areas

Contraindications (situations that should not be performed)

Those with bleeding disorders

Those using blood thinners (doctor decides according to the patient)

In the area to be treated or in the presence of systemic infection

In case of regional metastasis