Is rizatriptan (a triptan medication) safe for use during breastfeeding in a lactating woman with a history of migraine headaches, possibly with pre-existing liver or kidney disease, or taking other medications?

Rizatriptan Safety During Breastfeeding

Rizatriptan can be used during breastfeeding, though it should be reserved for moderate to severe migraine attacks when first-line treatments (acetaminophen or NSAIDs) have failed. 1, 2

Recommended Treatment Algorithm for Breastfeeding Mothers

First-Line Acute Treatment

• Start with acetaminophen (paracetamol) 1000 mg as the preferred initial medication for acute migraine in breastfeeding mothers 1, 2
• Ibuprofen is also considered safe and has been extensively used during lactation with no reported adverse effects 1, 2
• Other NSAIDs including diclofenac and naproxen are compatible with breastfeeding 2

Second-Line Treatment: Triptans Including Rizatriptan

• Rizatriptan should be reserved for moderate to severe attacks or when acetaminophen/NSAIDs provide insufficient relief 2
• The American Academy of Neurology considers sumatriptan (another triptan) safe during breastfeeding, with infant exposure through breast milk being minimal and well below therapeutic levels 1
• All triptans, including rizatriptan, are generally compatible with breastfeeding based on low milk transfer and absence of reported adverse effects in infants 3

FDA Labeling Information and Cautions

The FDA label for rizatriptan states: "It is not known whether this drug is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when rizatriptan benzoate is administered to a nursing woman." 4

• Animal studies show rizatriptan is extensively excreted in rat milk at levels 5-fold higher than maternal plasma, though this may not directly translate to humans 4
• The FDA recommends discussing the best way to feed your baby if taking rizatriptan 4

Important Clinical Considerations

Potential Breastfeeding-Related Side Effects

• Monitor for breast/nipple pain, painful milk ejection reflex, or decreased milk production - these are rare but reported adverse effects related to triptan use during breastfeeding 5
• The mechanism involves serotonin-receptor agonism causing vasoconstriction in breast vasculature and potential effects on prolactin levels 5
• These effects do not contraindicate triptan use but should be discussed with patients 5

Medication Overuse Prevention

• Limit rizatriptan use to fewer than 10 days per month to prevent medication overuse headache 6, 1
• This threshold is lower than for NSAIDs (which is 15 days per month) 6

Infant Monitoring

• Watch for unusual drowsiness, poor feeding, or other concerning symptoms in the infant, though these are rarely reported with triptan exposure through breast milk 2
• Infant serum drug concentration monitoring is not routinely necessary but can be considered if concerns arise 3

Preventive Treatment if Needed

If migraines are frequent and disabling enough to require preventive therapy:

• Propranolol is the first-choice preventive medication during breastfeeding due to its established safety profile 1, 2
• Preventive medications should be avoided unless clinically indicated due to frequent and disabling attacks 1

Common Pitfalls to Avoid

• Do not use opioids or butalbital-containing medications for migraine treatment in breastfeeding mothers 6
• Do not automatically discontinue breastfeeding when prescribing rizatriptan - the benefits of breastfeeding typically outweigh the minimal infant exposure risk 6, 3
• Do not prescribe ergotamine derivatives as alternatives, as these have more concerning safety profiles 3