Triptans During Pregnancy: Safety and Recommendations
Triptans should only be used during pregnancy under strict specialist supervision and reserved for cases where first-line treatments (paracetamol) and second-line options (NSAIDs in second trimester only) have failed, with sumatriptan being the preferred agent due to having the most safety data. 1, 2
First-Line and Second-Line Treatment Hierarchy
- Paracetamol (acetaminophen) 1000 mg is the first-line acute treatment for migraine during pregnancy due to its relatively safe profile 1, 2
- NSAIDs (such as ibuprofen) can only be used during the second trimester as a second-line option 1, 2
- Metoclopramide is safe for migraine-associated nausea throughout pregnancy 1, 2
Triptan Use: When and Which One
If paracetamol and NSAIDs (second trimester only) provide insufficient relief, triptans may be considered sporadically under strict specialist supervision. 1, 2
- Sumatriptan is the preferred triptan because it has the most extensive safety data from post-marketing surveillance 1, 2, 3
- Available evidence shows no significant increase in major congenital malformations with triptan exposure, particularly sumatriptan 4, 5, 6
- Preterm birth rates may be slightly elevated with triptan use, though causality is unclear 4
Evidence Quality and Limitations
The safety data for triptans in pregnancy comes primarily from:
- Post-marketing surveillance registries (strongest data for sumatriptan) 1, 4, 5
- A prospective cohort study of 432 triptan-exposed pregnancies showed no increased risk of major birth defects (ORadj 0.84; 95% CI 0.4-1.9), spontaneous abortions (ORadj 1.20; 95% CI 0.9-1.7), or preterm delivery (ORadj 1.01; 95% CI 0.7-1.5) compared to non-migraine controls 6
- Current data is sufficient to rule out large increases in birth defects but cannot exclude small increases in risk 5
Specific Populations Where Triptans Should Be Avoided
It is reasonable to avoid triptan agents in pregnant adolescents with:
- Hemiplegic migraine 1
- Basilar migraine 1
- Known vascular risk factors 1
- Prior cardiac or cerebral ischemia 1
- Renal or hepatic disease 1
Medications to Absolutely Avoid
- Ergotamine derivatives and dihydroergotamine are contraindicated due to oxytocic properties and potential fetal harm 1, 2
- Opioids and butalbital should be avoided due to risks of dependency, rebound headaches, and potential fetal harm 2
- CGRP antagonists (gepants) have insufficient safety data and should be avoided 2
Preventive Treatment During Pregnancy
Preventive migraine medications are best avoided during pregnancy but may be considered under specialist supervision for frequent, disabling attacks 1, 2
- Propranolol has the best safety data and is the first choice for prevention 1, 2
- Amitriptyline can be used if propranolol is contraindicated 1, 2
- Topiramate, candesartan, and sodium valproate are absolutely contraindicated due to known teratogenic effects and adverse fetal outcomes 1, 2
Postpartum and Breastfeeding
During breastfeeding, both paracetamol and sumatriptan are considered safe for acute migraine treatment 1, 7
- Ibuprofen is also safe during breastfeeding 1
- Propranolol remains the preferred preventive medication with the best safety profile 1, 7
- Potential adverse effects in breastfeeding mothers include painful breasts/nipples and decreased milk production due to triptan-induced vasoconstriction, though these do not contraindicate use 8
Clinical Pitfalls to Avoid
- Do not use triptans as first-line treatment in pregnancy—always try paracetamol first 1, 2
- Do not prescribe NSAIDs in the first or third trimester—only second trimester use is acceptable 1, 2
- Ensure specialist supervision when triptans are deemed necessary, as safety data remains limited 1
- Avoid medication overuse headache by limiting triptan use to <10 days/month 2