Treating migraine during pregnancy and breastfeeding
Migraine is a very common ailment in the reproductive age groups, with a peak prevalence of 25% between the 30th and 40th years.1 Generally, the symptoms of migraine improve during pregnancy, and return about a month after the birth. During the breastfeeding period, environmental factors, like a lack of sleep and stress, can further aggravate the situation. In 8.4% of the women, we witness a worsening of migraine during pregnancy, which can occur as early as the first trimester.2 A non-drug preventive approach (to avoid triggering or aggravating factors, ensuring an adequate diet and a sufficient number of hours of sleep, exercise and relaxation) should always be considered as the first choice. However, whilst drug use during pregnancy and breastfeeding should always be as limited as possible, in some cases the severity and intensity of the attacks is such that it is impossible to do without them. Suboptimal treatment of migraine can have significant consequences for both the mother and the foetus, including malnutrition, dehydration, sleep deprivation, stress, and depression.3 Some studies have also found an increased risk of cardiovascular complications, such as stroke, gestational hypertension and pre-eclampsia.4 Therefore, providing an adequate anti-migraine treatment to pregnant women is imperative, even though the choice of drugs represents a challenge. In fact, many of the drugs used in the treatment of migraine do not even have safety documentation that is sufficient to ensure safe use in pregnancy or whilst breastfeeding. For treatment, we mainly use paracetamol, NSAIDs and triptans. For migraine prevention, beta-blockers, anti-epileptics, and tricyclic antidepressants are mainly used. The ability to use these drugs or not in pregnancy and breastfeeding may depend on the gestational age and the specific parturient. The table summarizes schematically which choices can be recommended.5
Table I. The safety of drugs commonly used to treat migraine during the various stages of pregnancy and whilst breastfeeding
| Medications | Prenatal development | First trimester | Second trimester and early third trimester | End of the third trimester | Breastfeeding |
|---|---|---|---|---|---|
| TREATMENT (This classification presupposes occasional use, the risk may increase with frequent or excessive use) | |||||
| Paracetamol | S - considered safe | S - considered safe | S - considered safe | S - considered safe | S - considered safe |
| Sumatriptan | U - there is no evidence of risk to the foetus and mother | U - there is no evidence of malformations | U - there is no evidence of risk to the foetus and mother | U - there is no evidence of risk to the foetus and mother | S - considered safe |
| Other triptans | NR - there is no evidence of risk to the foetus and mother, but the data are limited | NR - there is no evidence of birth defects, but the data are limited | U - there is no evidence of risk to the foetus and mother | U - there is no evidence of risk to the foetus and mother | U - the majority of triptans are probably compatible with breastfeeding |
| NSAIDs (ibuprofen, diclofenac, naproxen) | NR - can increase the risk of miscarriage | NR - can increase the risk of malformations | The individual doses are considered safe in the second trimester, and occasional use up to 32nd week in the third trimester should not pose any risk to the foetus | E - risk of foetal damage and adverse effects in the mother if used after 32nd week | S -generally compatible with breastfeeding with ibuprofen considered the drug of first choice; avoid the use of aspirin and salicylates |
| PREVENTION | |||||
| Beta-blockers (metoprolol, propranolol) | U - there is no evidence of risk to the foetus and mother | U -reported occasionally increased risk of malformations, but causality is uncertain; in general there are no demonstrable teratogenic effects | U - risk of adverse foetal events, e.g. bradycardia | NR - risk of adverse outcomes in neonates, such as bradycardia, hypotension and hypoglycaemia | S - adverse events in children are unlikely |
| Tricyclic antidepressants (amitriptyline) | U - there is no evidence of risk to the foetus and mother | NR -little data is available: there is no evidence of teratogenic effects for the tricyclic antidepressants in general | NR - data very scarce, one study reported an increase in the risk of pre-eclampsia | NR - adverse reactions and neonatal abstinence syndrome cannot be excluded | U - limited excretion in milk, but available data is scarce; elimination alterations in prematurely born infants and neonates can lead to accumulation |
| Anti-epileptics (valproate) | E- increase in neural tube defects in the foetus | E - increased risk of many malformations | E - risk of adverse long-term effects on neurocognitive development | E - risk of long-term adverse effects on neurocognitive development | U - no risk in children, but there is risk of teratogenic effects if the mother becomes pregnant again |
| Anti-epileptics (topiramate) | E- there is no data, but the experience with other anti-epileptic drugs does not recommend its use | E - increased risk of orofacial malformations | E – scarce data, but we cannot exclude adverse mental and neuro-motor effects in children | E - scarce data, but we cannot exclude adverse mental and neuro-motor effects in children | NR - generally considered compatible with breastfeeding, but in the prematurely born and neonates medication can accumulate and cause adverse events |
| Legend S (safe) - drug considered safe; U (uncertain) - drug considered generally safe, but there are uncertainties related to, for example, specific drugs in the class at certain times of the pregnancy, or the data is scarce; NR (not recommended) - you cannot exclude an increased risk of adverse effects since there are studies that say that there is a risk or the lack of data supporting the safety; E (evidenced) - drugs for which the risk to the foetus outweigh the expected benefit to the mother | |||||
Azienda Ospedaliero Universitaria Pisana, Centro FV Toscana
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