What are the recommended treatments for headaches in breastfeeding mothers?

Headache Treatment in Breastfeeding Mothers

For acute headache treatment in breastfeeding mothers, use paracetamol (acetaminophen) 1000 mg as first-line therapy, followed by ibuprofen or other NSAIDs as second-line options, with sumatriptan reserved for severe migraine attacks unresponsive to first-line agents. 1, 2, 3

Acute Treatment Approach

First-Line Medications (Safe and Preferred)

• Paracetamol (acetaminophen) 1000 mg is the safest first-line option, as the amount transferred to breast milk is significantly less than pediatric therapeutic doses 1, 2
• Ibuprofen has been used extensively for postpartum pain and during lactation, with established safety during breastfeeding 1, 3
• Diclofenac transfers only small amounts into breast milk and has been used extensively during lactation 1
• Naproxen is widely used after caesarean section and breastfeeding may continue as normal, despite its longer half-life 1
• Ketorolac shows low levels in breast milk without demonstrable adverse effects in neonates 1

Second-Line Medications (Use with Monitoring)

• Sumatriptan is considered safe during breastfeeding and has the most safety data among triptans, though infant exposure can be minimized by avoiding breastfeeding for 24 hours after treatment 2, 4, 5, 6
• Eletriptan is excreted in human milk, but infant exposure can be minimized by avoiding breastfeeding for 24 hours after treatment 4, 6
• Morphine is recommended as the opioid of choice if strong analgesia is required, though the infant should be monitored for signs of sedation and respiratory depression with repeated doses 1

Antiemetic Adjuncts

• Metoclopramide 10 mg (oral or IV) is safe and effective for migraine-associated nausea during breastfeeding 1, 2
• Prochlorperazine 25 mg (oral or suppository) can relieve both nausea and headache pain directly 2, 3

Medications to Absolutely Avoid

• Codeine is contraindicated due to genetic polymorphism in CYP2D6 metabolism—ultrarapid metabolizers can transfer dangerous amounts of morphine to infants, with documented cases of infant death 1
• Aspirin in analgesic doses should not be used due to association with Reye's syndrome in infants 1, 6
• Ergotamine derivatives and dihydroergotamine are contraindicated throughout breastfeeding 2, 3
• Opioids and butalbital-containing medications should be avoided due to risks of infant sedation, respiratory depression, dependency, and medication-overuse headache 2, 3

Preventive Treatment (If Needed)

• Propranolol has the best safety profile if preventive medication is required for frequent and disabling migraines during breastfeeding 2, 3
• Topiramate, candesartan, and sodium valproate remain contraindicated during breastfeeding as during pregnancy 2

Critical Monitoring Parameters

• Limit acute treatment frequency to prevent medication-overuse headache: less than 10 days per month for triptans and less than 15 days per month for acetaminophen/NSAIDs 2
• Monitor infants for signs of drowsiness, poor feeding, or respiratory depression when any systemic medication is used, particularly opioids if unavoidable 1
• Observe timing of breastfeeding relative to medication administration—for medications with shorter half-lives, breastfeeding immediately before taking the medication minimizes infant exposure 1

Non-Pharmacological Interventions

• Maintain adequate hydration with regular fluid intake throughout the day 1, 2
• Ensure regular meals to avoid hypoglycemia as a migraine trigger 1, 2
• Secure consistent, sufficient sleep patterns despite the challenges of caring for an infant 1, 2
• Identify and avoid specific migraine triggers through use of a headache diary 1, 2
• Consider biofeedback, relaxation techniques, massage, and ice packs as adjunctive non-pharmacological approaches 2

Important Clinical Pitfalls

• Do not use traditional "migraine cocktails" containing NSAIDs, triptans, and opioids together—use only the antiemetic component (metoclopramide or prochlorperazine) if combination therapy is considered 2
• Avoid prescribing rescue medications containing opioids or butalbital for home use 2
• Do not assume all triptans have equal safety data—sumatriptan has the most robust evidence during breastfeeding 2, 5, 6
• Remember that medication overuse headache is a significant risk with frequent acute treatment, particularly problematic when treatment options are already limited 1, 2