Beyond Headache: Migraine in Pregnancy and Its Obstetric–Vascular Consequences

Migraine is one of the most common and disabling neurologic disorders affecting women of childbearing age. Although many individuals experience improvement during pregnancy, particularly those with migraine without aura, clinical response is variable, and relapse is common in the early postpartum period. Importantly, improvement in headache frequency does not imply benign disease. Population-based cohort studies and systematic reviews link maternal migraine to increased risks of adverse obstetric outcomes, especially hypertensive disorders of pregnancy (including preeclampsia) and preterm birth, with some evidence suggesting higher preeclampsia risk in migraine with aura. Pregnancy’s prothrombotic and hemodynamically complex physiology may amplify vulnerability to vascular complications, and large national inpatient analyses associate migraine during pregnancy with higher odds of both ischemic and hemorrhagic stroke. Clinically, headache assessment in pregnancy and postpartum should avoid diagnostic anchoring when red flags suggest secondary etiologies. Management should follow a stepwise approach emphasizing nonpharmacologic measures first, with carefully selected acute and preventive pharmacotherapy when maternal benefit outweighs fetal risk. Recognizing migraine as a marker of obstetric and vascular risk supports individualized risk assessment and multidisciplinary care to improve maternal outcomes.