Migraine patterns in women are closely linked to various reproductive stages. During puberty, migraine prevalence becomes more pronounced in females compared with males, and remains so throughout the remaining life span. An estimated 40% of women experience migraine during the reproductive life cycle, and one-fourth of reproductive-aged women suffer from migraines.1 Up to 70% of female migraine patients report changes in headache frequency or severity during menstruation, hormonal contraceptive use, pregnancy, and menopause.1

A particular challenge in this population is the effective management of migraine during pregnancy and lactation while minimizing the risk for harm to the fetus. For many women with migraine, the frequency, intensity, and duration of headaches improve during pregnancy. Some research has shown similar effects with lactation, although findings have been mixed overall.2

In a recent paper published in Current Pain and Headache Reports,2 Simy K. Parikh, MD, from the Jefferson Headache Center at Thomas Jefferson University in Philadelphia, Pennsylvania, reviewed evidence pertaining to preventive and abortive therapies for migraine during pregnancy and lactation.2 Her findings are highlighted here.

Preventive treatment during pregnancy

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  • Among nutraceutical options, findings suggest that riboflavin (400 mg/day) and coenzyme Q10 (100 mg 3×/day) may be effective in preventing migraine if initiated 3 months before pregnancy.
  • Anticonvulsants, including valproic acid and topiramate, should generally be avoided because of demonstrated risks for cognitive and motor impairment and for congenital birth defects, respectively.
  • Among beta blockers, atenolol has been linked to low birth weight when used during the first trimester. The use of other beta blockers warrants close fetal monitoring for issues such as bradycardia and intrauterine growth retardation.
  • Tricyclic antidepressants are associated with cardiac and craniofacial malformations, whereas serotonin-norepinephrine reuptake inhibitors have not been linked to these outcomes.
  • Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers should be avoided during pregnancy. Use of these agents in the second and third trimesters may lead to pulmonary, renal, and skull malformations. Evidence for use in the first trimester is inconclusive.

Abortive treatment during pregnancy

  • As prostaglandin synthetase inhibitors, nonsteroidal anti-inflammatory drugs increase the “risk for premature closure of the ductus arteriosus during use in the third trimester and are therefore contraindicated during that time,” whereas a recent study reported no adverse effects with the use of ibuprofen during the first trimester.2
  • Findings indicate that metoclopramide is safe for use in pregnancy, including during the first trimester.
  • No significant adverse outcomes were noted in a prospective observational cohort study of 432 pregnant women taking triptans.3 As sumatriptan has the most supporting evidence, this is the recommended option among the triptans.

Preventive treatment during lactation

  • Topiramate is likely safe for use during breastfeeding, whereas valproic acid should be avoided.
  • Propranolol is the preferred beta blocker for use during lactation because of its low maternal plasma levels
  • With maternal use of tricyclic antidepressants, as “active metabolites are secreted into breast milk in small amounts[, infants] should be monitored for sedation, poor feeding, and anticholinergic side effects.”2
  • Although angiotensin-converting enzyme inhibitors and angiotensin receptor blockers do not generally transfer to human breast milk in significant amounts, there have been concerns about renal toxicity when used in premature infants.

Abortive treatment during lactation

  • Ibuprofen is the preferred nonsteroidal anti-inflammatory drug, based on studies showing very low levels of the drug in breast milk, even with frequent doses.
  • Naproxen has been linked to drowsiness and vomiting in infants.
  • Aspirin should be avoided because of the associated risk for Reye’s syndrome.
  • Sumatriptan and eletriptan have low concentrations in breast milk.

“It is important for clinicians to think critically about pharmacologic options, as medications misattributed as teratogens or as a lactation risk could lead to poor treatment of episodic migraine in pregnancy, while use of true teratogens could lead to unnecessary exposure,” Dr Parikh concluded.2

To get a better idea of current treatment trends in this population, Neurology Advisor conducted a roundtable discussion with several experts across neurology and headache medicine, as well as women’s health: Teshamae Monteith, MD, a neurologist at the University of Miami Health System n Florida, and a member of the American Academy of Neurology; Huma Sheikh, MD, assistant clinical professor of neurology at Mount Sinai Beth Israel, New York City; and Paru S. David, MD, FACP, NCMP, assistant professor of medicine in the Division of Women’s Health-Internal Medicine at Mayo Clinic, Phoenix, Arizona.

This article originally appeared on Neurology Advisor