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Safety of triptans for migraine headaches during pregnancy and breastfeeding
Silvia Duong, RPh, Pina Bozzo, Hedvig Nordeng, PhD and Adrienne Einarson, RN
A patient who just found out that she is pregnant and suffers from migraine headaches informs me that she has been taking naratriptan. She indicates that she is planning on breastfeeding her baby and might need to continue treatment. How safe are the medications from this class of drugs during pregnancy and breastfeeding?
Accumulated data suggest that exposure to sumatriptan during pregnancy does not increase the risk of birth defects above the baseline rate. There are currently insufficient data to confirm the safety of other triptans; however, evidence to date is reassuring. Information regarding safety of triptans while breastfeeding is limited but also reassuring, as the minimal amounts excreted into the milk are insufficient to cause any adverse effects on the breastfeeding infant.
Une patiente qui vient dapprendre quelle est enceinte et souffre de migraine ma dit quelle prenait du naratriptan. Elle ma aussi informé quelle avait lintention dallaiter son bébé et quelle aurait peut-être besoin de continuer son traitement. Dans quelle mesure les médicaments de cette classe sont-ils sécuritaires durant la grossesse et lallaitement?
Selon les données recueillies, lexposition au sumatriptan durant la grossesse naugmente pas le risque danomalies congénitales au-delà de la normale. Les données sont actuellement insuffisantes pour confirmer linnocuité des autres triptans; par ailleurs, les données publiées scientifiques jusquà maintenant sont rassurantes. Les renseignements concernant la sécurité des triptans durant lallaitement sont limités, mais eux aussi rassurants, étant donné que les quantités minimes excrétées dans le lait sont insuffisantes pour causer des effets indésirables sur le nourrisson allaité.
Migraine headache is a common neurologic condition that affects many women of childbearing age. In Canada, approximately 15% of women between 25 and 54 years of age suffer from migraines.1 Observational studies have indicated that, as levels of estrogen increase, 55% to 90% of mothers experience decreases in both the frequency and severity of migraines during their second and third trimesters.1–4 However, 25% of women with a history of migraines experience minimal changes in frequency or might even experience an increase in attacks.1,5 To date, there are no reports that indicate the occurrence of migraines increases the risk of spontaneous abortion, other pregnancy-related complications, or major malformations.4–6 However, inadequate treatment of migraines might have a serious effect on maternal well-being (eg, sleep deprivation, poor nutrition, dehydration, increased stress, and depression).4
Treatment of migraines
Nonpharmacologic measures are usually tried first because of their proven efficacy and innocuity. Strategies include relaxation techniques, appropriate duration of sleep, stress management, massages, application of ice packs, and biofeedback. To prevent recurrence of migraines, pregnant women should also avoid triggers such as lack of sleep, emotional stress, strong odours, and skipping meals.2,4,5 Among therapeutic options, analgesics are most often the initial drug of choice to manage migraine attacks. Acetaminophen remains the drug of choice during pregnancy because of its lack of teratogenic effects.7 However, for many women, especially with severe migraines, it might not be effective. Consequently, a substantial number of women have been treated with triptans before becoming pregnant and might need to continue treatment during pregnancy and breastfeeding.8
Triptans: pharmacologic properties and mechanism of action
The 5-hydroxytryptamine (5-HT) agonists (triptans) are effective for the acute management of migraines, but they do not prevent future attacks. In contrast to analgesics, the efficacy of triptans is due to the specifically targeted pathogenesis of migraine headaches. Migraine is considered a neurovascular disorder: the sensitization and activation of the trigeminal ganglia promote inflammation of the nerves supplying the meningeal blood vessels and in turn cause dilation of the blood vessel walls.4 Triptans alleviate migraines by binding to serotonin 5-HT1B/1D receptors, thereby leading to vasoconstriction and inhibition of neuronal inflammation.3,9 There are currently 6 triptans available in Canada: almotriptan, eletriptan, naratriptan, rizatriptan, sumatriptan, and zolmitriptan. Although the first triptan (ie, sumatriptan) has been on the market for more than 2 decades, there is a paucity of published evidence regarding the safety of triptans as a group in human pregnancy.
Safety studies in pregnancy
Available data are currently derived from manufacturer-sponsored pregnancy registries, as well as retrospective and prospective observational studies. Evidence-based information regarding sumatriptan is the most abundant, most likely because it was the prototype of the drug class and has been available for many years. Pregnancy registry data are available for 3 triptans: sumatriptan, naratriptan, and rizatriptan. To date, the risk of major malformations has been reported to be similar to the baseline risk in the general population (1% to 3%). The rates of major malformations were 4.5% for sumatriptan in 494 pregnancies; 2.2% for exposure to naratriptan during the first trimester in 52 pregnancies; and 3.1% for rizatriptan in 51 pregnancies.10,11 Because pregnancy cases are gathered on a voluntary basis, the accumulated data from company registries are limited by the lack of comparison groups and recall bias. Furthermore, these data need to be interpreted with caution in light of the small sample sizes and insufficient power to reliably detect an increased risk of major malformations.
To date, 3 published prospective comparative studies confirmed no increased risk of major malformations reported with exposure to sumatriptan during pregnancy.12–14 Two subsequent systematic reviews also found no association between teratogenicity and use of sumatriptan during pregnancy.15,16 Most recently, as part of the Norwegian Mother and Child Cohort Study, a large observational, prospective cohort study evaluated fetal outcomes following exposure to triptans during pregnancy. The authors identified 1535 pregnant women who received triptans during their pregnancies; 90% of the women used triptans in the first trimester and 65% used them during the second or third trimesters. These women were compared with 373 migraine controls (ie, women treated with triptans 6 months before pregnancy) and 68 021 nonmigraine controls (ie, no reported use of triptans). In the first trimester, 47% (n = 653) of triptan users were treated with sumatriptan; 23.6% (n = 328) with rizatriptan; 17.5% (n = 243) with zolmitriptan; 12.9% (n = 179) with eletriptan; 2.2% (n = 31) with naratriptan; and 2.1% (n = 29) with almotriptan. There was no association between triptan use during the first trimester and an increased risk of major malformations (odds ratio [OR] 1.0, 95% confidence interval [CI] 0.7 to 1.2). Triptan therapy during the second or third trimesters was associated with a small increase in the risk of atonic uterus (OR 1.4, 95% CI 1.1 to 1.8) and blood loss (> 500 mL) during labour (OR 1.3, 95% CI 1.1 to 1.5), but not with a risk of adverse fetal outcomes.17
Triptans and breastfeeding
Regarding the use of triptans during breastfeeding, human data remain scarce. In a study with 5 nursing women who had received subcutaneous sumatriptan, it was estimated that the infants received, at the most, 3.5% of the maternal dose through breast milk.18 As a rule, a medication with a relative infant dose of less than 10% of the administered maternal dose is considered compatible with breastfeeding.19 In addition, given the low oral bioavailability of sumatriptan of 14% when compared with the subcutaneous route of 96%, it is expected that the amounts ingested by suckling infants would be small and would most likely not cause adverse effects. The American Academy of Pediatrics also considers sumatriptan as usually compatible with breastfeeding.20 Furthermore, a small study indicates that a single 80-mg oral dose of eletriptan results in a relative infant dose of 0.02% of the maternal dose; however, the concentration of the active metabolite (with a longer plasma half-life) was not measured in the breast milk.21
The accumulated evidence from sumatriptans pregnancyregistry and other studies suggest that this drug is a safe therapeutic option for the treatment of migraine attacks in pregnant women. More studies are needed to confirm the safety of the other triptans in pregnancy; however, evidence to date is reassuring. In addition, sumatriptan is considered compatible with breastfeeding, as minimal amounts are excreted into milk.
Women who suffer from these migraine headaches, which often render them unable to carry out tasks of daily living, can use triptans during pregnancy and breastfeeding without fear of harming their unborn children or infants.
Can Fam Physician
Vol. 56, No. 6, June 2010, pp.537 - 539
Copyright © 2010 by The College of Family Physicians of Canada
- Ferreira E. Grossesse et allaitement. Guide thérapeutique. Montreal, QC: Editions du CHU Sainte-Justine; 2007. Google Scholar
- Fox AW, Diamond ML, Spierings EL. Migraines during pregnancy: options for therapy. CNS Drugs 2005;19(6):465-81. CrossRef | Medline | Google Scholar
- Hilaire ML, Cross LB, Eichner SF. Treatment of migraine headaches with sumatriptan in pregnancy. Ann Pharmacother 2004;38(10):1726-30. Epub 2004 Aug 17. Medline | Google Scholar
- Evans EW, Lorber KC. Use of 5-HT1 agonists in pregnancy. Ann Pharmacother 2008;42(4):543-9. Epub 2008 Mar 18. CrossRef | Medline | Google Scholar
- Pfaffenrath V, Rehm M. Migraine in pregnancy: what are the safest treatment options? Drug Saf 1998;19(5):383-8. CrossRef | Medline | Google Scholar
- Menon R, Bushnell CD. Headache and pregnancy. Neurologist 2008;14(2):108-19. CrossRef | Medline | Google Scholar
- Babb M, Koren G, Einarson A. Treating pain during pregnancy. Can Fam Physician 2010;56:25-7. Abstract/FREE Full Text
- Rebordosa C, Kogevinas M, Horváth-Puhó E, Nørgård B, Moreales M, Czeizel AE, et al. Acetaminophen use during pregnancy: effects on risk of congenital abnormalities. Am J Obstet Gynecol 2008;198(2):178.e1-7. CrossRef | Medline | Google Scholar
- Soldin OP, Dahlin J, O'Mara DM. Triptans in pregnancy. Ther Drug Monit 2008;30(1):5-9. Medline | Google Scholar
- GlaxoSmithKline. The sumatriptan/naratriptan/Treximet pregnancy registry. Interim report. Wilmington, NC: Kendle International Inc; 2009. Available from: http://pregnancyregistry.gsk.com/documents/sum-nar_report_spring2009_final.pdf. Accessed 2009 Sep 29.
- Fiore M, Shields KE, Santanello N, Goldberg MR. Exposure to rizatriptan during pregnancy: post-marketing experience up to 30 June 2004. Cephalalgia 2005;25(9):685-8. Abstract/FREE Full Text
- Källén B, Lygner PE. Delivery outcome in women who used drugs for migraine during pregnancy with special reference to sumatriptan. Headache 2001;41(4):351-6. CrossRef | Medline | Google Scholar
- O'Quinn S, Ephross SA, Williams V, Davis RL, Gutterman DL, Fox AW. Pregnancy and perinatal outcomes in migraineurs using sumatriptan: a prospective study. Arch Gynecol Obstet 1999;263(1–2):7-12. CrossRef | Medline | Google Scholar
- Shuhaiber S, Pastuszak A, Schick B, Matsui D, Spivey G, Brochu J, et al. Pregnancy outcome following first trimester exposure to sumatriptan. Neurology 1998;51(2):581-3. Abstract/FREE Full Text
- Fox AW, Chambers CD, Anderson PO, Diamond ML, Spierings EL. Evidence-based assessment of pregnancy outcome after sumatriptan exposure. Headache 2002;42(1):8-15. CrossRef | Medline | Google Scholar
- Loder E. Safety of sumatriptan in pregnancy: a review of data so far. CNS Drugs 2003;17(1):1-7. CrossRef | Medline | Google Scholar
- Nezvalová-Henriksen K, Spigset O, Nordeng H. Triptan exposure during pregnancy and the risk of major congenital malformations and adverse pregnancy outcomes: results from the Norwegian Mother and Child Cohort Study. Headache 2010 Jan 28. Epub ahead of print. Google Scholar
- Wojnar-Horton RE, Hackett LP, Yapp P, Dusci LJ, Paech M, Ilett KF. Distribution and excretion of sumatriptan in human milk. Br J Clin Pharmacol 1996;41(3):217-21. CrossRef | Medline | Google Scholar
- Hale TW. Medications and mothers’ milk. 13th ed. Amarillo, TX: Hale Publishing; 2008. Google Scholar
- American Academy of Pediatrics Committee on Drugs. Transfer of drugs and other chemicals into human milk. Pediatrics 2001;108(3):776-89. Abstract/FREE Full Text
- Relpax (eletriptan hydrobromide) [product monograph]. Kirkland, QC: Pfizer; 2004.