Is sumatriptan (Imitrex) or propranolol (Inderal) safe to use during pregnancy?

Safety of Sumatriptan and Propranolol in Pregnancy

Propranolol is relatively safe for use during pregnancy with appropriate monitoring, while sumatriptan should only be used sporadically under strict specialist supervision when first-line treatments fail. 1, 2

Propranolol Safety Profile

Propranolol is considered a safe first-line agent for chronic prophylaxis during pregnancy, though ideally avoided in the first trimester. 3 The ACC/AHA/HRS guidelines specifically list propranolol with a Class IIa recommendation (Level of Evidence C-LD) for ongoing management in pregnant patients, noting it has a longer record of safety compared to other beta-blockers. 3

Key Risks and Monitoring Requirements

• Intrauterine growth retardation (IUGR) is the primary concern, particularly with first trimester exposure and longer duration of treatment. 3, 4 This effect is less pronounced than with atenolol, which should be completely avoided. 3, 4

• The FDA label classifies propranolol as Pregnancy Category C, noting that intrauterine growth retardation, small placentas, and congenital abnormalities have been reported in neonates whose mothers received propranolol during pregnancy. 5

• Neonatal monitoring is essential at birth for bradycardia, hypoglycemia, and respiratory depression. 5

Clinical Management Algorithm for Propranolol

• Use the lowest effective dose (typically 80-160 mg daily for migraine prophylaxis) and titrate according to clinical response. 3, 1

• Implement serial fetal growth monitoring via ultrasound, particularly during second and third trimesters when hemodynamic load is highest. 4

• Monitor for fetal bradycardia throughout pregnancy. 4

• Arrange early neonatal follow-up after hospital discharge to assess for hypoglycemia and metabolic abnormalities. 4

Sumatriptan Safety Profile

Sumatriptan may be used sporadically under strict specialist supervision when other treatments fail, with most safety data supporting sumatriptan specifically among the triptans. 1, 2 This represents third-line therapy after paracetamol and NSAIDs (second trimester only). 1, 2

Evidence Base

• The FDA label classifies sumatriptan as Pregnancy Category C, noting that animal studies showed embryolethality, fetal abnormalities, and increased pup mortality at doses approximately 2-5 times the maximum recommended human dose. 6

• Current human data is sufficient to rule out large increases in birth defects but not small increases in risk. 7 Available literature indicates no additional risk of birth defects compared with the 3-5% baseline incidence in the general population. 8

• Sumatriptan is excreted in breast milk, but infant exposure can be minimized by avoiding breastfeeding for 12 hours after treatment. 6

When Sumatriptan May Be Considered

• Only when paracetamol (1000 mg, preferably as suppository) fails as first-line treatment. 1, 9

• Only during second trimester if NSAIDs like ibuprofen are also insufficient or contraindicated. 1, 2

• Use must be sporadic, not regular, and under specialist supervision. 1, 2

Treatment Algorithm for Migraine in Pregnancy

First-Line: Non-Pharmacological Approaches

• Adequate hydration and regular meals 1
• Sufficient and consistent sleep patterns 1
• Appropriate physical activity 1
• Trigger identification and avoidance 1

Second-Line: Acute Treatment

1. Paracetamol 1000 mg (preferably suppository) - safest option throughout pregnancy 1, 2, 9
2. NSAIDs (ibuprofen) - only during second trimester, avoid first and third trimesters 1, 2
3. Sumatriptan - sporadic use only, under specialist supervision, when above options fail 1, 2

Preventive Treatment (Only if Absolutely Necessary)

• Propranolol 80-160 mg daily - first choice with best safety profile 1, 2
• Amitriptyline - second-line if propranolol contraindicated 1, 2

Critical Pitfalls to Avoid

• Never use atenolol - it causes more pronounced IUGR than propranolol and should be completely avoided. 3, 4

• Avoid all medications in first trimester when possible, as this is when risk of congenital malformations is greatest. 3

• Do not use ergotamine derivatives or dihydroergotamine - these are absolutely contraindicated due to potential fetal risks. 1

• Avoid topiramate, sodium valproate, and candesartan - these are teratogenic and contraindicated. 1, 2

• Consider preeclampsia - any new headache in a pregnant woman with hypertension should be considered part of preeclampsia until proven otherwise. 1

Postpartum and Breastfeeding

• Paracetamol remains the preferred acute medication during breastfeeding. 1, 2

• Both ibuprofen and sumatriptan are considered safe during breastfeeding (avoid breastfeeding for 12 hours after sumatriptan). 1, 2, 6

• Propranolol is the first-choice preventive agent during breastfeeding with superior safety profile. 1, 2