What are the recommended treatments for migraines in breastfeeding women?

Migraine Treatment During Breastfeeding

For breastfeeding women with migraines, paracetamol (acetaminophen) is the preferred first-line acute treatment, with ibuprofen and sumatriptan also considered safe options. 1, 2

Acute Treatment Options

First-line treatments:

• Paracetamol (Acetaminophen): Safest option with minimal transfer into breast milk 1, 3
• Ibuprofen: Low levels in breast milk, considered safe 4, 3
• Sumatriptan:
  • Safe during breastfeeding with minimal infant exposure 1, 3
  • To minimize exposure, avoid breastfeeding for 12 hours after administration 5
  • Has the most safety data among triptans 1

Second-line treatments:

• Other NSAIDs (with caution):

  • Diclofenac, ketoprofen, naproxen: Compatible but use with caution 3
  • Avoid high-dose aspirin due to risk of Reye's syndrome 4

• Metoclopramide: Can be used for nausea associated with migraine 1, 3

Medications to avoid:

• Ergotamine derivatives: Contraindicated during breastfeeding 3
• Opioids: Risk of sedation or apnea in infants 4

Preventive Treatment Options

If preventive therapy is necessary due to frequent and disabling attacks:

First-line preventive options:

• Propranolol: First choice with best safety profile 1, 6, 3
  • Dosage: 80-160 mg once or twice daily in long-acting formulations 1

Second-line preventive options:

• Amitriptyline: Consider if propranolol is contraindicated 1, 6, 3
  • Dosage: 10-100 mg at night 1

Preventive medications to avoid:

• Topiramate: Contraindicated during lactation 1, 3
• Sodium valproate: Contraindicated 1
• Candesartan: Not recommended 1
• Atenolol, nadolol: Contraindicated 3

Non-Pharmacological Approaches

Non-pharmacological approaches should be considered first-line, especially for preventive treatment:

• Regular sleep schedule
• Consistent meal times
• Adequate hydration
• Stress management techniques
• Cognitive behavioral therapy
• Relaxation techniques (abdominal breathing exercises, progressive muscle relaxation)
• Supplements that may be considered:
  • Magnesium (400-600mg daily)
  • Riboflavin (400mg daily)
  • Coenzyme Q10 2

Important Considerations

• Breastfeeding itself may be protective against migraines due to stable estrogen levels 7
• When using medications, consider timing administration immediately after breastfeeding to minimize infant exposure
• The benefits of breastfeeding often outweigh the minimal risks associated with most migraine medications 4
• Consultation with a specialist is recommended for women with frequent, severe migraines requiring medication during breastfeeding
• Maintain a headache diary to track frequency, severity, triggers, and medication response 2

Treatment Algorithm

1. Start with non-pharmacological approaches
2. If acute treatment is needed:
   • First try paracetamol
   • If ineffective, use ibuprofen
   • If still ineffective, consider sumatriptan (avoid breastfeeding for 12 hours)
3. If preventive treatment is needed (≥2 attacks/month or significant disability):
   • First try propranolol
   • If contraindicated or ineffective, consider amitriptyline
4. Monitor response and adjust treatment as needed

Remember that untreated severe migraines can negatively impact both mother and infant through decreased quality of life and ability to care for the infant, so appropriate treatment is important.