What are the recommended treatments for migraines in breastfeeding women?

Migraine Treatment During Breastfeeding

Paracetamol (acetaminophen) is the first-line medication for acute migraine treatment in breastfeeding women, with ibuprofen and sumatriptan also considered safe options. 1, 2

Acute Treatment Options

• Paracetamol (acetaminophen) is the safest first-line option for acute migraine attacks during breastfeeding due to its favorable safety profile 1, 3
• Ibuprofen is considered safe during breastfeeding with low levels in breast milk, making it a good second-line option 4, 2
• Sumatriptan is compatible with breastfeeding, though mothers should avoid breastfeeding for 12 hours after treatment to minimize infant exposure 5, 2
• Metoclopramide can be safely used for nausea associated with migraine during breastfeeding 1, 2

Medications to Avoid for Acute Treatment

• Aspirin (acetylsalicylic acid) should be avoided, particularly high-dose formulations, due to potential toxicity concerns including association with Reye's syndrome 4, 2
• Ergotamine derivatives and dihydroergotamine are contraindicated during breastfeeding due to potential risks 1, 2
• Opioids and butalbital-containing medications should be avoided due to risks of sedation, apnea, and dependency 1, 4

Preventive Treatment Options

• Propranolol has the best safety profile and is the first choice for preventive therapy in breastfeeding women 1, 3
• Metoprolol is another beta-blocker considered safe during lactation 2
• Amitriptyline can be used if beta-blockers are contraindicated 1, 2
• Verapamil is considered safe for migraine prevention during breastfeeding 2
• Certain SSRIs (escitalopram, paroxetine, sertraline) are compatible with breastfeeding if needed for comorbid conditions 2

Preventive Medications to Avoid

• Topiramate and valproate require caution during breastfeeding 2
• Atenolol and nadolol are contraindicated during breastfeeding 2
• Zonisamide is not recommended during breastfeeding 4
• CGRP antagonists (gepants) have insufficient safety data and should be avoided 1

Non-Pharmacological Approaches

• Non-pharmacological approaches should be considered first-line before initiating medication therapy 3, 6
• Identifying and avoiding migraine triggers is crucial for effective management 1
• Maintaining adequate hydration, regular meals, sufficient sleep, and regular physical activity can help manage migraines 1, 6

Important Clinical Considerations

• Medication overuse headache can occur with frequent use of acute medications (≥15 days/month with NSAIDs; ≥10 days/month with triptans) 1
• The steady estrogen levels during lactation may serve as a protective factor against migraines for some women 6
• When using sumatriptan, breastfeeding should be avoided for 12 hours after treatment to minimize infant exposure 5
• Regular monitoring is essential when medications are used during breastfeeding, especially for preventive treatments 1
• Treatment decisions should balance the benefits of breastfeeding against the risks of untreated migraine, which can impact both maternal well-being and infant care 4, 7

Treatment Algorithm for Migraine in Breastfeeding Women

1. Acute Treatment:

   • First-line: Paracetamol (acetaminophen) 1000 mg 1, 3
   • Second-line: Ibuprofen 400-600 mg 4, 2
   • Third-line: Sumatriptan (with 12-hour breastfeeding interruption) 5, 2
   • For nausea: Metoclopramide 1, 2

2. Preventive Treatment (if experiencing ≥3 severe attacks per month):

   • First-line: Propranolol 1, 3
   • Second-line: Amitriptyline 1, 2
   • Third-line: Verapamil 2