Breastfeeding and Migraine Medications
When we first become moms we face all sorts of new challenges and changes in our lives and in our bodies. Those of us managing migraines have an extra challenge: optimizing our own health and treatment plans while also doing what is best for our baby. Unfortunately, this often feels like scary and uncharted territory.
I suffered from 26 years of daily migraines that started at the age of four. By the time I got up the courage to have a child I had been married fourteen years and was well into the “advanced maternal age” timeframe. In my first pregnancy, my migraines became so severe that my doctor scheduled an early C-section at 38 weeks. When my daughter was born I stared at her in bewilderment. How could someone with a health history that caused so much pain and suffering produce a perfectly healthy baby?
If you have chronic migraines and you’ve been brave enough to make it through pregnancy I applaud you. It is no small task. But let’s face it, the challenges do not end there. If you choose to breastfeed, you will now need to work with your healthcare team to decide on a plan that will keep your migraines under control and be safe for your baby until he or she is weaned.
Recommendations and providers’ opinions vary widely on this topic. This is not surprising since it has been historically unpopular to include pregnant or lactating women in clinical trials meant to determine the safety and efficacy of medications. While the spirit of this exclusion was to protect unborn children and breastfeeding infants from the unknown effects of medications, it has left us a bit ignorant of how to safely manage illness in pregnant and lactating women.
It is important not to minimize the risks of poorly controlled migraine disease during both pregnancy and lactation. Migraine can cause increased stress on the baby and the mother, along with sleep deprivation and depression. Risks become more severe if migraines are accompanied by nausea and vomiting which can lead to dehydration and suboptimal nutrition status1. While as many as 80-90% of women who suffer from migraine actually find some relief during pregnancy (I was lucky enough to be one of them in my second pregnancy, despite my experience of increased migraines in my first), migraine disease will return to its previous level within a month of delivery in more than half of new mothers1,2. There is conflicting evidence surrounding whether the stable estrogen levels during lactation can delay the return of a woman’s previous migraine pattern3. Regardless of hormone levels, the lack of sleep, stress, and unpredictable schedule of being a new mom are migraine triggers for many women.
Our culture puts a lot of pressure on pregnant and lactating moms to avoid medications. This pressure is compounded by the fact that we live in a world that really does not understand migraine. The fact is that leaving mom to be sick and suffering is not what is best for her or her baby. So what are the best options available to women in this phase of life and how is this determined?
Nearly all medications diffuse into your breast milk from your blood. The higher your blood level, the higher the level will be in your breast milk. The measurement used to determine if a medication is at a safe level for your baby is called Relative Infant Dose or RID. It is a measure of the dose the infant receives via breast milk expressed as a percentage of the mother’s medication dose. Each medication has its own specific RID value. What is important to know about RID is that once it is greater than 10, there is concern exposure through breast milk could be harmful to the infant. The fact is that this rarely occurs4,5. We will get into how this relates to specific medications used for migraine in a moment.
There are other factors that come into play including the amount of milk ingested and the infant’s age. Older infants (6-18 months) are at the lowest risk from medication exposure through breast milk, and those between 2 to 6 months are at moderate risk. Infants at highest risk are those born premature or those with medical conditions that may impair their ability to clear the medication from their system. Another factor is drug half-life. Medications with long half-lives are more likely to accumulate in breast milk and reach the baby at higher concentrations. (An example of this that relates to migraine is Topamax vs Trokendi XR. Both are topiramate, but Trokendi is extended release and has a longer half-life than Topamax).
One last point of interest is the timing of medication dose related to when you feed your baby. While this recommendation may differ depending on the drug, some specialists recommend taking your medication right at the time of breastfeeding or immediately after. This practice is thought to lead to the lowest concentration of drug in breast milk at the time of feeding. Timing of medication, avoidance of long-acting forms of medications, watching the baby for signs of sleepiness, irritability, or other known signs of your specific medicine are all important general considerations when taking medications while breastfeeding your baby.
Let’s start with the abortive migraine medications that are the safest for the baby during breastfeeding. Acetaminophen (or Tylenol, RID 8.81%) and ibuprofen (RID 0.65%) are among the safest options if they happen to be effective for you. Triptans have a reported RID of 3.0, but can range up to 15.3 at peak concentration. But even at its highest concentration, sumatriptan has not been associated with any problems in infants who are exposed through breast milk because triptans are not absorbed well orally. Among triptans, sumatriptan has been the most studied in lactation and is preferred for this reason. Naproxen and diclofenac (NSAIDs much like ibuprofen)are also considered compatible with breastfeeding; however, ibuprofen is preferred because it has been more extensively studied and has a shorter half-life1.
What about options for migraine prophylaxis? The simplest of the migraine prophylactic options when breastfeeding are the anti-depressants: amitriptyline (RID 1.9-2.8) and sertraline (Zoloft, RID 0.4-2.2). But do not worry, if these are not helpful to you there are other options. For women who find that beta-blockers are important for their migraine prevention, propranolol (RID 0.3-0.5) and metoprolol (RID 1.4) are the preferred choices during lactation2. Recommendations for women taking beta-blockers while breastfeeding is to pay special attention to whether your baby shows signs of lethargy or a slow heart rate. Verapamil (RID .15-.2) is considered the safest calcium channel antagonist during lactation. Much like beta- blockers, it is recommended to monitor babies of breastfeeding mothers taking verapamil for signs of low blood pressure, low heart rate, and also peripheral edema2.
Two anticonvulsant medications effective for migraine have been studied in the setting of breastfeeding. Data on topiramate is interesting in that it has a high RID (24.5), yet babies of mothers who breastfed while taking 150-200 mg/day of topiramate had very low levels of the drug in their system. These babies also did not show side effects from the drug. It is advised that infants be monitored for diarrhea, sleepiness, and proper weight gain and development. It is also recommended that their plasma level of the drug be monitored somewhere around the age of 4-8 weeks2. Valproic acid (RID 1.4-1.7) has some characteristics that make it interesting in lactation. While this medication is contraindicated in pregnancy due to side effects in the unborn child, it has been found that very little of it enters breast milk. Instead, valproic acid stays bound to proteins in the mother’s blood. If valproic acid is an important part of your migraine regimen while breastfeeding, it is recommended that the infant’s plasma levels be monitored.
Unfortunately, we do not yet have much data on the use of either anti-CGRP medications or onabotulinumtoxinA (Botox) during lactation. There is hesitation to prescribe anti-CGRP medications to women who are pregnant or breastfeeding because CGRP acts as an important neurotransmitter that plays a role in blood flow to the uterus and placenta. It is also instrumental in various aspects of the developing infant6,7. However, there is a thought-provoking statement in the Drugs and Lactation Database indicating that since erenumab (Aimovig) is such a large molecule it is unlikely to be found in high amounts in breast milk, and it would most likely be destroyed by the baby’s gastrointestinal tract once ingested8. Botox also has not been well studied in this area and it is unknown if Botox is found in human milk.
Interest in cannabis research is rapidly increasing; however, our knowledge of cannabis use in the setting of migraine or during breastfeeding is still very limited. Two very recently published articles have helped shed light on this area; however, we still do not have very solid answers. The first study was a review looking at cannabinoids in migraine, headache, and pain. This study concluded that high-quality research on cannabis and migraine is limited; however, the use of cannabis in chronic pain is supported by well-controlled clinical trials. Therefore, it is possible that cannabis could also be effective in migraine due to their similar mechanisms9. Another very small study looked at the transfer of delta-9-tetrahydrocannabinol, the most psychoactive component of cannabis, into breast milk. They calculated an RID of 2.5 for delta-9-tetrahydrocannabinol and concluded that its transfer after inhalation of cannabis was low. However, the authors cautioned mothers that the long-term neurobehavioral effects of cannabis on the developing brain are still unknown10. The takeaway message from this is that we are not yet certain if cannabis is helpful to migraine patients or if it is safe to use while breastfeeding.
There is enough data available on many of the medications used to combat migraine to help guide a practical conversation between you and your healthcare provider about how to manage your migraines while breastfeeding. Do not assume you have to suffer in silence because you are choosing to breastfeed your child. Your baby needs you at your best. It is good to be assertive when optimizing our migraine treatment plans because this is how we optimize our lives.
(1) Amundsen S, Nordeng H, Nezvalova-Henriksen K, Stovner LJ, Spigset O. Pharmacological treatment of migraine during pregnancy and breastfeeding. NatRev Neurol. 2015 Apr;11(4):209-19.
(2) Devanzo R, Bua J, Paloni G, Facchina G. Breastfeeding and migraine drugs. Eur J Clin Pharmacol 2014 Nov;70(11):1313-24.
(3) Wells RE, Turner DP, Lee M, Bishop L, Strauss L. Managing migraine during pregnancy and lactation. Curr Neurol Neurosci Rep. 2016 Apr;16(4):40.
(4) Hotham N, Hotham E. Drugs in breastfeeding. Austr Prescr. 2015 Oct;38(5):156-9.
(5) Anderson PO, Sauberan JB. Modeling drug passage into human milk. Clin Pharmacol Ther 2016 Jul;100(1):42-52.
(6) Yallampalli C, Chauhan M, Endsley J, Sathishkumar K. Calcitonin gene related family peptides: importance in normal placental and fetal development. Adv Exp Med Biol. 2014;814:229-40.
(7) Yallampalli C, Chauhan M, Sathishkumar K. Calcitonin gene-related peptides in vascular adaptations, uteroplacental circulation, and fetal growth. Curr Vasc Pharmacol 2013 Sep:11(5):641-54.
(8) Drugs and Lactation Database (LactMed). Bethesda (MD): National Library of Medicine (US): 2006. Link: https://toxnet.nlm.nih.gov/cgi-bin/sis/search2
(9) Baron EP. Medicinal properties of cannabinoids, terpenes, and flavonoids in cannabis, and benefits in migraine, headache, and pain: an update on current evidence in cannabis science. Headache 2018 Jul;58(7):1139-1186.
(10) Baker T, Datta P, Rewers-Felkins K, Thompson H, Kallem RR, Hale TW. Transfer of inhaled cannabis into human breast milk. Obstet Gynecol. 2018 May;131(5):783-788. Baker T, Datta P, Rewers-Felkins K, Thompson H, Kallem RR, Hale TW. Transfer of inhaled cannabis into human breast milk. Obstet Gynecol. 2018 May;131(5):783-788.
MEET THE AUTHOR
Dr. Lindsay Weitzel experienced chronic daily migraine from the time she was four years old until she was thirty. Her constant migraine attacks caused enough damage to give her complex regional pain syndrome (a ceaseless pain like burning fire) down the right side of her face, head, neck, and arm. Lindsay believes that having no memory without daily pain gave her a unique perspective on living with and fighting off her disease.
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