Is rizatriptan (a triptan) safe to use during breastfeeding?

Rizatriptan Safety During Breastfeeding

Rizatriptan is generally considered safe to use during breastfeeding as infant exposure through breast milk is minimal, with an estimated relative infant dose of only 0.9% (range 0.3-1.4%) of the maternal dose.

Evidence on Rizatriptan in Breastfeeding

The safety profile of rizatriptan during breastfeeding is supported by clinical data showing minimal transfer into breast milk:

• A lactation study of 19 breastfeeding women with migraine found that rizatriptan had a mean relative infant dose (RID) of only 0.9% (range 0.3-1.4%) 1. This is well below the 10% threshold generally considered safe for breastfeeding.

• Triptans as a class have shown low levels of excretion in breast milk, with no reported adverse effects in breastfed infants with occasional use 2, 3.

Clinical Decision-Making Algorithm for Rizatriptan in Breastfeeding

Step 1: Assess Necessity

• Determine if rizatriptan is clinically indicated for moderate to severe migraine attacks
• Consider if first-line treatments (acetaminophen, NSAIDs) have failed

Step 2: Evaluate Risk-Benefit Ratio

• Benefits: Effective migraine relief for mother, allowing better care of infant
• Risks: Minimal infant exposure (0.9% of maternal dose)

Step 3: Implement Safety Measures

• Use the lowest effective dose
• Time administration to minimize infant exposure:
  • Take medication immediately after breastfeeding
  • Consider pumping and discarding milk at peak concentration (though generally unnecessary given low transfer)

Potential Side Effects to Monitor

While rizatriptan is considered compatible with breastfeeding, mothers should be aware of potential breastfeeding-related adverse effects:

• Some women have reported painful breasts/nipples, painful milk ejection reflex, or decreased milk production 2
• These effects are thought to be related to the serotonin-receptor agonist properties of triptans, which may cause vasoconstriction in breast tissue 2
• These effects don't negatively impact the overall compatibility with breastfeeding but should be monitored

Important Considerations

• The FDA label for rizatriptan does not specifically contraindicate its use during breastfeeding but recommends discussing with healthcare providers 4
• Rizatriptan is preferred over some other triptans like naratriptan (which has a higher RID of 5.0%) for breastfeeding mothers, especially during the neonatal period 1
• Sumatriptan is another good option with a similar safety profile (RID 0.7%) 1

Common Pitfalls to Avoid

1. Unnecessary discontinuation of breastfeeding: The minimal transfer of rizatriptan into breast milk does not warrant interruption of breastfeeding.

2. Untreated maternal migraine: Leaving migraine untreated can negatively impact maternal well-being and ability to care for the infant.

3. Overestimating risk: Many healthcare providers may be overly cautious about medication use during breastfeeding without considering current evidence.

4. Using contraindicated alternatives: Some older migraine treatments like ergotamine are contraindicated during breastfeeding 3, making rizatriptan a safer choice.

In conclusion, rizatriptan can be safely used by breastfeeding mothers with migraine, with minimal risk to the infant based on the most recent and highest quality evidence available.