Medical management of migraine treatment during pregnancy can be challenging for many physicians and pregnant women. Options for the treatment of primary headache disorders during pregnancy, including migraine, are often limited due to both known and unknown risks to the developing fetus posed by many standard pharmaceutical treatments.
Due to the favorable safety profiles in non-pregnant patients, researchers and medical providers have increasing interest and utilization in neuromodulation therapy for the treatment of migraine.
Neuromodulation is a therapeutic modality that alters the behavior of part of the nervous system, typically by delivering electrical or chemical stimulation to a specific neural pathway or network. Neuromodulation, which often comes in the form of medical devices, has multiple, evidence-based indications across the spectrum of chronic neurological disease including pain, epilepsy, rehabilitation, movement disorder, and psychiatric disorders.
“Neuromodulatory devices are a safe, effective, and well-tolerated non-pharmacological option for migraine and other primary headache disorders,” according to an article on using neuromodulatory devices during pregnancypublished in Current Pain and Headache Reports. “Although evidence of safety and tolerability use in pregnancy is limited, they may serve as a therapeutic alternative or adjunct to improve the care of our pregnant patients.”
An overview of migraine in pregnancy
Migraine disproportionately affects women, being approximately 3 times more common in women than men. Roughly 20% of women experience migraine, and migraine is the leading cause of years lived in disability among women aged 15 to 49 years — within the window of childbearing years. Hormone fluctuations in women are also known to worsen the severity of migraine.
Typically, migraine symptoms improve during pregnancy, but patient experiences vary. According to a prospective study published in Cephalalgia, the severity of migraine gradually improves as most pregnancies progress. Improvement was seen in 46.8% of women during the first trimester, then in 83% and 87.2% of women in the second and third trimesters, respectively. The rates of migraine remission also gradually improve during pregnancy, with just 10.6% of women experiencing migraine remission in the first trimester and 78.7% of women experiencing complete remission in the third trimester.
While the course of migraine improves or reaches remission for a majority of pregnant women, this effect is not experienced by every pregnant woman. For example, migraines with aura are less likely to improve during pregnancy than migraines without aura. Furthermore, the persistence of migraine during pregnancy has been linked to higher rates of maternal complications such as pre-eclampsia, preterm birth, and worsened mental health outcomes.
In the American Registry of Migraine Research observational study, approximately 20% of women with migraine chose to avoid pregnancy due to migraine.
The limits of pharmacological treatment of migraine disorder in pregnant women
Some pharmacological abortive and preventative treatments for migraine are known to cause birth defects, and the potential risks of many pharmacological treatments are relatively unknown. Many pharmaceutical therapies and medications traditionally considered benign and safe to use in pregnancy have come under increasing scrutiny as recent data suggest some associated fetal risk after exposure.
For example, “the use of beta blockers for migraine prevention during pregnancy may warrant close monitoring,” physicians wrote in Practical Neurology. A population-based cohort study published in BMJ Open shows an association between beta-blocker use during pregnancy and infants being born small for gestational age, preterm birth, and perinatal mortality.
Though acetaminophen has been considered first-line treatment for acute migraine therapy, a recent study published in Nature Mental Health found that acetaminophen use during pregnancy was associated with 5.22% odds of attention-deficit/hyperactivity disorder diagnosis in children, potentially mediated through upregulation of placental immune factors. According to the Agency for Healthcare Research and Quality (AHRQ) systematic review, other pregnancy-associated risks associated with acetaminophen use include premature closure of the ductus arteriosus and early childhood respiratory disorders with frequent use during pregnancy. Nonsteroidal anti-inflammatory medications such as ibuprofen are often avoided due to the risk of spontaneous miscarriage in the first trimester and the risk of premature closure of the ductus arteriosus in the third trimester.
Though triptans are known to be more effective than acetaminophen at minimizing migraine pain, little is known about the safety of triptan use during pregnancy. Triptan use during pregnancy remains controversial as its use during pregnancy may be associated with increased rates of spontaneous abortion.
In the last decade, calcitonin gene-related peptide (CGRP) receptor-blocking agents have emerged as another effective treatment for migraine. CGRP receptor-blocking agents are an important migraine treatment outside of pregnancy, and a recent position statement by the American Headache Society calls for CGRP targeting therapies to be considered as first-line options for the prevention of migraine.
Unfortunately, the safety of CGRP receptor-blocking agents during pregnancy is unknown. Based on potential mechanistic teratogenic potential during pregnancy and teratogenic effects demonstrated in animal models, expert consensus recommends against the use of CGRP therapies in pregnant women and adolescents who are known to be pregnant, breastfeeding or planning to become pregnant within 6 months.
Could neuromodulation be a safer alternative to pharmaceuticals for migraine in pregnancy?
As of 2025, there are five non-invasive neuromodulation devices cleared by the United States Food and Drug Administration (US FDA) for the prevention and treatment of migraine. Each device leverages different modalities or stimulation targets that act on neural networks associated with migraine.
Noninvasive external trigeminal nerve (eTNS) stimulation produced by CEFALYⓇ is a medical device placed on your forehead using an adhesive electrode. It works by stimulating the trigeminal nerve implicated in migraine pathogenesis.
External concurrent occipital and trigeminal neurostimulation (eCOTNS) produced by RelivionⓇ is placed around the head like a headband and stimulates both the trigeminal and occipital nerves.
electroCoreⓇ produces noninvasive vagal nerve stimulation (nVNS) via a device placed on the neck designed to stimulate the vagus nerve to reduce migraine pain signals.
A single-pulse transcranial magnetic stimulator (sTMS), eNeuraⓇ , sends magnetic pulses to the brain to reduce migraine pain, especially with aura.
A remote electrical neuromodulator (REN) produced by NerivioⓇ is an armband that goes around the upper arm. It stimulates nerves to block incoming pain signals associated with migraines.
Multiple studies of neuromodulation devices among nonpregnant women show that they are generally safe and effective in managing migraine. Most neuromodulation therapies are noninvasive and result in no serious adverse effects. Adverse effects are fully reversible, typically with cessation of treatment. Given the favorable safety and efficacy profile, neuromodulation is an increasingly popular option among people with migraines seeking nonpharmacological treatments.
Despite the popularity of neuromodulation for migraine during pregnancy, little research examines its safety and efficacy. One case series reported migraine outcomes and safety of 3 pregnant women with migraine using sTMS. There was a demonstrated reduction in pain severity, shorter attack duration and reduction of migraine associated symptoms with no pregnancy or delivery complications.
A retrospective study of 171 women compared safety outcomes in pregnant women with migraines using and not using REN therapy. The findings demonstrated no significant differences between REN and non-REN users in gestational age, newborn weight, miscarriage rate, birth defect rate, preterm birth rate, stillbirth rate, and three-month newborn development milestones, suggesting that REN is a safe therapy option for pregnancy.
To date, there are no clinical studies that have established the safety of eTNS use for migraine during pregnancy; however, there is an active IRB-approved research pregnancy registry, sponsored by CEFALY Technology, to collect data and understand maternal and fetal outcomes in women with migraine who use neuromodulation and/or pharmaceutical therapies. Many providers consider neuromodulation therapies a safe option during pregnancy as they are noninvasive, targeted therapies with minimal and fully reversible adverse effects in clinical studies of the general population.
Neuromodulation may be a safe alternative for people who are pregnant, but additional research regarding the safety of these neuromodulation therapies in pregnancy is needed.
