Migraine Therapies
IABLE
Medications Migraine Therapies

Migraine Therapies

Migraine therapy often includes combination therapy of nutritional supplements, abortive and preventive therapy with adjunct medication used for symptoms. Medications are broken down and summarized into these categories below.

For further detailed information and references on specific medications, please refer to Lactmed, e-lactancia, Infant Risk, or Mother to Baby.

Abortive Therapies

  • Non-Opioid Analgesics: acetaminophen/Tylenol, NSAIDs (aspirin, celecoxib/Celebrex, diclofenac, ibuprofen/Advil/Motrin, naproxen, ketorolac/Toradol), Excedrin (aspirin + acetaminophen + caffeine). These medications are considered safe in the breastfeeding dyad. There is no absolute indication to pump and dump. For more information, see the section on Pain Medications.
  • Triptans (sumatriptan/Imitrex, zolmitriptan/Zomig, frovatriptan/Fova, rizatriptan/Maxalt, naratriptan/Amerge): For those that have been studied, generally there are low levels found in breast milk. According to Amundsen et. Al (1), when zolmitriptan is used with propranolol, the zolmitriptan dose received by the breastfed infant increases substantially so another agent should be considered for those on propranolol. For those triptans that have not been studied (naratriptan, frovatriptan) an alternative may be preferred, especially while breastfeeding a newborn or preterm infant, until more is known (1). There is no absolute indication to pump and dump, though a well-studied triptan (such as sumatriptan) is preferred and zolmitriptan should not be used with propranolol in lactating individuals.
  • Gepants (rimegepant/Nurtec, ubrogepant/Ubrelvy): Data is limited on this class of medications in lactation. The amount in breastmilk is likely low so shared decision making with patients is needed if this medication is necessary. Alternative medications should be considered due to the lack of data, especially when breastfeeding a newborn or preterm infant.
  • 5HT1F Receptor Agonist (Reyvoq/lasmiditan): Alternative medications should be considered due to the lack of data, especially when breastfeeding a newborn or preterm infant.

Oral Preventative Therapies

  • Antiepileptics (topiramate/Topamax, divalproex sodium/Depakote, valproic acid/valproate sodium, carbamazepine/Tegretol, oxcarbazepine/Trileptal): Due to theoretical risks, these medications should be used with close monitoring of infants for side effects as noted below. Generally, there is no absolute indication to pump and dump, but alternative medications should be considered for some medications in this class due to the concerns noted below. For more information on antiepileptic medications, see the section on Anticonvulsants.
    • Topiramate/Topamax: Doses of up to 200 mg daily in lactating individuals are associated with relatively low levels of this medication in the breastfed infant. There have been rare case reports of sedation and diarrhea in breastfed infants as noted in LactMed. Two studies noted no long-term adverse effects on growth and development in 6 infants total (2, 3). While infants should be monitored for diarrhea, drowsiness, irritability, adequate weight gain, and development (especially with younger infants or the use of multiple psychotropic medications), there is no absolute indication to pump and dump.
    • Divalproex/valproic acid: Little is known about divalproex, but it is quickly metabolized into the active drug valproic acid. Valproic acid levels are low in breast milk. There is a theoretical risk of liver damage and low platelets in the infant with valproic acid use; therefore infants should be monitored for jaundice and abnormal bruising or bleeding. When valproic acid is used in combination with other sedating psychotropic medications, the infant should also be monitored for sedation. Alternative medications should be considered due to the risks to the infant. If alternatives are not available, providers should engage in shared decision making with patients if this medication must be used and infants should be monitored for jaundice, bruising, or bleeding.
    • Carbamazepine: Carbamazepine’s active metabolite is found in relatively high concentrations in breastmilk; however, it is normally below an anticonvulsant therapeutic window. With its use, infants should be monitored for sedation, poor sucking, withdrawal symptoms and liver abnormalities. While infants should be monitored for side effects (sedation, poor sucking, withdrawal symptoms, liver abnormalities), there is no absolute indication to pump and dump.
    • Oxacarbazepine: While infants should be monitored for side effects (such as drowsiness), there is no absolute indication to pump and dump.
  • Antihypertensives: There is no absolute indication to pump and dump with most antihypertensive medications. For more detailed information, see the section on Blood Pressure Medications.
    • Beta Blockers (metoprolol, propranolol, timolol, atenolol, nadolol, nebivolol, pindolol)
    • Calcium Channel Blockers (nicardipine, nifedipine, nimodipine, verapamil)
    • Angiotensin Receptor Blockers (candesartan, telmisartan)
    • Ace Inhibitors (lisinopril)
  • Antidepressants: While infants should be monitored for side effects (such as sedation) with the use of antidepressants or combinations of psychotropic medications in lactating individuals, but there is no absolute indication to pump and dump. Link to the section on Psych meds when done.
    • Tricyclic antidepressants (amitriptyline/Elavil, nortriptyline/Pamelor)
    • Serotonin-norepinephrine reuptake inhibitors (venlafaxine/Effexor, duloxetine/Cymbalta)

Injectable/Infusion Preventative Therapies

  • Calcitonin-gene related peptide (CGRP) antagonists (eptinezumab/Vyepti, erenumab/Aimovig, fremanezumab/Ajovy, galcanezumab/Emgality): There is no information available on the use of these medications during lactation. These medications are monoclonal antibodies and are very large peptide proteins such that the medication concentration in breastmilk is suspected to be low. Due to the nature of being a peptide molecule, the small amount that may enter the breast milk would likely be destroyed by the infant’s gastrointestinal tract and not be absorbed by the infant. While data is limited, there is no absolute indication to pump and dump.
  • Botulinum Toxin A (Botox): The local use of this medication in the breastfeeding dyad is considered safe. There is no absolute indication to pump and dump.

Adjunct Therapies

  • Nutraceuticals (magnesium, riboflavin, coenzyme Q10, melatonin): Many supplements are generally considered safe in lactation. These supplements are normal components of breastmilk, and little data has been gathered about exogenous supplementation while breastfeeding. Supplements are not required to go through extensive pre-marketing approval from the U.S. Food and Drug Administration and may contain other ingredients and their safety or effectiveness may not be proven.
    • Melatonin: Melatonin has very low oral bioavailability and occurs naturally in human milk, but it is known to have a relatively long half-life in preterm infants. Watch for infant sedation with high doses. There is no absolute indication to pump and dump.
    • Magnesium: Magnesium can theoretically delay the onset of lactation, but there is no absolute indication to pump and dump.
  • Antiemetics (prochlorperazine/Compazine, metoclopramide/Reglan, Benadryl, phenergan/Promethazine, ondansetron/Zofran): There is no absolute indication to pump and dump with these medications.
    • Promethazine: When promethazine is used in repeated doses, infants should be observed for sedation. Promethazine can decrease prolactin, which could interfere with establishing lactation especially if used during labor or in combination with pseudoephedrine. While infants should be monitored for sedation and lactating individuals should be counseled of the risks to milk production in the scenarios noted above, there is no absolute indication to pump and dump.
    • Diphenhydramine: Infrequent use of diphenhydramine is considered safe, however like promethazine, larger doses or frequent dosing can cause effects like sedation in the infant or decrease in milk production. Therefore, in nursing mothers, an antiemetic without potent histamine blocking action is preferred. While infants should be monitored for sedation and lactating individuals should be counseled of the risks to milk production, there is no absolute indication to pump and dump.
    • Metoclopramide: Metoclopramide can cause depression and an alternative may be preferred in mothers immediately postpartum or who are at an increased risk for depression. Metoclopramide can markedly increase milk production, so caution is needed if used regularly. While lactating individuals should be counseled on the risks to milk production, there is no absolute indication to pump and dump.

References

  1. Amundsen S, Nordeng H, Fuskevåg OM, et al. Transfer of triptans into human breast milk and estimation of infant drug exposure through breastfeeding. Basic Clin Pharmacol Toxicol. 2021;128:795–804. DOI: https://doi.org/10.1111/bcpt.13579.
  2. Öhman I, Vitols S, Luef G, et al. Topiramate kinetics during delivery, lactation, and in the neonate: Preliminary observations. Epilepsia. 2002;43:1157–60. DOI: https://doi.org/10.1046/j.1528-1157.2002.12502.x
  3. Öhman I, Luef G, Tomson T. Topiramate kinetics during lactation. Epilepsia. 2007;48 Suppl. 7:156–7. DOI: https://doi.org/10.1111/j.1528-1167.2006.01370_8.x
  4. Ailani J, Burch RC, Robbins MS. The American Headache Society consensus statement: update on integrating new migraine treatments into clinical practice. Headache: The Journal of Head and Face Pain. 2021; 61(7): 1021-1039. DOI: https://doi.org/10.1111/head.14153.
  5. American Academy of Neurology Summary of Evidence-based Guideline for Clinicians. Update: pharmacologic treatment for episodic migraine prevention in adults. 2012, reaffirmed 2015, currently being updated. https://www.aan.com/Guidelines/home/GuidelineDetail/536. Accessed July 1 2022.
  6. Orr SL, Friedman BW, Christie S, Minen MT, Bamford C, Kelley N, Tepper D. Management of adults with acute migraine in the emergency department: the American headache society evidence assessment of parenteral pharmacotherapies. Headache: The Journal of Head and Face Pain. 2016; 56(6): 911-940. DOI: https://doi.org/10.1111/head.12835.