What are the recommended treatments for headaches in breastfeeding mothers?

Headache Treatment in Breastfeeding Mothers

For acute headache treatment in breastfeeding mothers, paracetamol (acetaminophen) is the preferred first-line medication, with ibuprofen and sumatriptan also considered safe options. 1

Acute Treatment Approach

First-Line Medications (Safe and Recommended)

• Paracetamol (acetaminophen) is the preferred acute medication for headache during breastfeeding, with the best safety profile 1
• Ibuprofen is also considered safe and can be used as an alternative first-line option 1, 2
• Low-dose aspirin may not be associated with fetal/child adverse effects, though high-dose aspirin is contraindicated 3

Second-Line Medications (Safe with Good Evidence)

• Sumatriptan is considered safe during breastfeeding, as infant exposure through breast milk is minimal and well below therapeutic levels 1, 2, 4
• Eletriptan has low levels in breast milk and may be used 2
• Diclofenac is compatible with breastfeeding but warrants caution 3

Adjunctive Therapy for Nausea

• Metoclopramide is safe and can be used for nausea associated with headache 2, 3

Caffeine Considerations

• Caffeine may be offered with a maximum dose of 200-300 mg per day during breastfeeding (lower than the 900 mg limit for non-breastfeeding patients) 1
• Avoid multiple caffeine sources to prevent adverse effects in the infant 1

Preventive Treatment (When Clinically Indicated)

First-Line Preventive Medication

• Propranolol is the recommended first choice for preventive therapy during breastfeeding, as it has the best safety profile among preventive medications 1, 5
• The infant receives only a minimal dose through breast milk—far below therapeutic levels—with no need to interrupt nursing 5
• Metoprolol is also safe during breastfeeding 3

Alternative Preventive Options

• Amitriptyline may be used if propranolol is contraindicated, though it should be used with caution 1, 3
• Verapamil (calcium channel blocker) is compatible with breastfeeding 3

Medications to Avoid

• Atenolol and nadolol are contraindicated during breastfeeding 3
• Topiramate is contraindicated during lactation 1
• Sodium valproate must not be used 1

Important Clinical Considerations

Multimodal Analgesia Strategy

• Regular multimodal analgesia including acetaminophen and NSAIDs should be offered to all patients unless contraindicated 1
• Short-term opioids may be considered if multimodal analgesia is ineffective, but long-term opioid use is not recommended 1

Common Pitfalls to Avoid

• Aspirin toxicity: High-dose aspirin is associated with Reye's syndrome risk and should be avoided 2
• Opioid concerns: Sedation or apnea in the infant is a concern with opioid use during breastfeeding 2
• Medication overuse: Discourage medication overuse to prevent medication overuse headache 1

When to Escalate Care

• If acute medication provides insufficient pain relief, referral to specialist care is indicated 1
• Preventive medications are best avoided unless clinically indicated due to frequent and disabling attacks 1