Safe Migraine Medications During Breastfeeding
Paracetamol (acetaminophen) 1000 mg is the first-line acute treatment for migraine during breastfeeding, with ibuprofen and sumatriptan also considered safe options. 1, 2
Acute Treatment Options
First-Line: Paracetamol
- Paracetamol remains the preferred acute medication during breastfeeding due to its excellent safety profile and minimal transfer into breast milk. 1, 2
- The recommended dose is 1000 mg, which can be repeated as needed while avoiding medication overuse (limit to <15 days per month). 1
- Studies show the amount of paracetamol an infant ingests via breast milk is significantly less than the pediatric therapeutic dose. 3
Second-Line: NSAIDs
- Ibuprofen is considered safe during breastfeeding and has been used extensively for postpartum pain with no adverse effects reported. 3, 1, 2
- Diclofenac is also compatible with breastfeeding, with only small amounts detected in breast milk and extensive safe use during lactation. 3
- Naproxen can be used despite its longer half-life, as it is widely used after caesarean section without complications. 3
- Ketorolac shows low levels in breast milk without demonstrable adverse effects in neonates. 3
Triptans for Severe Attacks
- Sumatriptan is considered safe during breastfeeding and has the most safety data among triptans. 1, 2, 4
- The FDA label states that infant exposure can be minimized by avoiding breastfeeding for 12 hours after treatment, though this may not be necessary based on clinical practice guidelines. 5
- Eletriptan has particularly low levels in breast milk according to research data. 4
- Recent pharmacovigilance data identified potential adverse effects including painful breasts/nipples, painful milk ejection reflex, and decreased milk production, likely due to vasoconstriction from serotonin-receptor agonism—however, these do not negatively impact overall compatibility with breastfeeding. 6
Antiemetics
Preventive Treatment Options
First-Line: Propranolol
- If preventive medication is required postpartum, propranolol is recommended as it has the best safety profile among all preventive options. 1, 2
- The recommended dose is 80-160 mg daily in long-acting formulations, given once or twice daily. 2
- Propranolol has minimal transfer into breast milk, making it safer than alternatives like topiramate or sodium valproate. 2
Second-Line: Amitriptyline
- Amitriptyline can be considered if propranolol is contraindicated, though it has less favorable safety data. 2
- The FDA label notes that amitriptyline is excreted into breast milk (levels of 135-151 ng/mL found in breast milk), but a decision should balance the importance of the drug to the mother against potential risks. 7
- Amitriptyline may be superior for mixed migraine and tension-type headache patterns. 2
Medications to Avoid
Absolutely Contraindicated
- Opioids and butalbital-containing medications should not be used due to risks of dependency, rebound headaches, and potential harm to the infant. 1
- High-dose aspirin should be avoided due to association with Reye's syndrome, though low-dose aspirin for antiplatelet action is acceptable if strongly indicated. 3, 8
- Ergotamine derivatives and dihydroergotamine are contraindicated. 1
Use with Caution
- Atenolol and nadolol are not recommended due to higher transfer into breast milk. 8
- Topiramate and valproate warrant caution during breastfeeding. 8
Important Clinical Considerations
Medication Overuse Prevention
- Limit acute treatment to <10 days per month for triptans and <15 days per month for paracetamol/NSAIDs to prevent medication overuse headache. 1
Non-Pharmacological Approaches
- Always recommend staying well hydrated, maintaining regular meals, securing sufficient and consistent sleep, and engaging in regular physical activity. 1, 2
- Identifying and avoiding migraine triggers is crucial for effective management. 1