Management of Rimegepant (Nurtec) and Amitriptyline (Elavil) During Pregnancy
A 21-year-old pregnant female should discontinue Nurtec (rimegepant) but may continue Elavil (amitriptyline) if clinically necessary for her condition.
Rimegepant (Nurtec) in Pregnancy
Safety Profile
- Rimegepant is a calcitonin gene-related peptide (CGRP) receptor antagonist used for both acute treatment and prevention of migraines 1.
- There is extremely limited safety data regarding the use of CGRP antagonists during pregnancy 2.
- Only one published case report documents rimegepant exposure during pregnancy, and in that case, the medication was discontinued early in the first trimester 2.
Recommendation
- Discontinue rimegepant immediately upon confirmation of pregnancy.
- The lack of adequate safety data makes it impossible to ensure fetal safety with continued use.
- While one case report showed no adverse effects when the drug was discontinued early in pregnancy, there are no studies supporting continued use throughout pregnancy 2.
Amitriptyline (Elavil) in Pregnancy
Safety Profile
- Amitriptyline is a tricyclic antidepressant commonly used for various conditions including migraine prophylaxis.
- There is more established safety data for amitriptyline during pregnancy compared to newer agents like rimegepant.
- A case report has documented successful use of amitriptyline during pregnancy for cyclic vomiting syndrome, resulting in a healthy term neonate 3.
Recommendation
- Amitriptyline may be continued during pregnancy if clinically necessary for symptom control.
- The benefits of maintaining maternal health and controlling symptoms may outweigh potential risks in many cases.
- Use the lowest effective dose to minimize fetal exposure.
Alternative Management Strategies for Migraine
Non-pharmacological Approaches
- Trigger avoidance (identify and avoid personal migraine triggers)
- Regular sleep schedule
- Adequate hydration
- Stress management techniques
- Biofeedback and relaxation techniques
Alternative Medications
- If medication is necessary for migraine control during pregnancy, consider:
- Acetaminophen (safest analgesic in pregnancy)
- Low-dose aspirin (may be used in first and second trimesters)
- Note that NSAIDs should be avoided in the third trimester due to risk of premature closure of the ductus arteriosus 4
Follow-up Recommendations
Monitoring
- Regular prenatal visits to monitor maternal and fetal well-being
- Assessment of migraine frequency and severity
- Evaluation of medication efficacy and side effects
Postpartum Considerations
- Reassess medication needs after delivery
- If breastfeeding is planned, evaluate compatibility of medications with lactation
Important Caveats
- The decision to continue or discontinue medication during pregnancy should prioritize both maternal health and fetal safety.
- Untreated severe migraines can negatively impact maternal quality of life and potentially affect pregnancy outcomes.
- Medication changes should be implemented with appropriate medical supervision.
- Document the risk-benefit discussion thoroughly in the medical record.