How do you approach the management of poorly controlled migraines during pregnancy?

This is an excellent question and area of frequent discussion.

You can start with Lidocaine nerve blocks: occipital, supra-orbital, and temporal. Sometimes, just IV fluids will help for acute migraines. Other options include Reglan, caffeine, and APAP.

If in the second trimester, I will do steroid taper for the patient. Sumatriptan and Eletriptan have been used and are the best studied of the triptans during pregnancy.

Prevention is more tricky. If it’s a planned pregnancy then beta blockers and...

As first-line abortive treatment, I recommend Tylenol 1000 mg + Reglan 10 mg up to 2x per day and limiting to 2 days per week or less.

Imitrex 100 mg as needed as second-line.

Lidocaine peri-cranial nerve blocks (no steroid) as first-line. If I have to use a preventative medication, then a beta blocker as a first-line and amitriptyline as a second-line. If they qualify for Botox, I have also used Botox in pregnancy.

Other prevention options are Nerivio and acupuncture.

As cycle breakers, 3-day...

A very good question for which the answer requires more space than is offered here. I cover it in a 10-page chapter in my recently released book (HEADACHES: Why You Have Them - What You Can Do About Them). It is generally looked upon exclusively from a neurological perspective, while medical issues are much more important, in my opinion. It is also the topic of a paper I published with the late Thomas D. Sabin (Spierings & Sabin, PMID 26703001).