Triptans in Pregnancy: Use with Caution Under Specialist Supervision
Triptans, particularly sumatriptan, may be used sporadically during pregnancy under strict specialist supervision when first-line treatments fail, though they are not first-line agents and pregnancy remains a relative contraindication. 1
Treatment Hierarchy for Acute Migraine in Pregnancy
First-Line Treatment
- Acetaminophen (paracetamol) 1000 mg is the first-line acute treatment for migraine during pregnancy due to its relatively safe profile 1
- Acetaminophen can be combined with caffeine for additional benefit 1
Second-Line Treatment
- NSAIDs such as ibuprofen can be used only during the second trimester as a second-line option 1
- NSAIDs must be avoided in the first and third trimesters due to fetal risks 1
Third-Line Treatment: Triptans
- Sumatriptan may be used sporadically when other treatments fail, but only under strict specialist supervision 1
- Sumatriptan has the most safety data among all triptans due to longer market availability 1, 2
- The FDA classifies sumatriptan as Pregnancy Category C, meaning animal studies showed fetal abnormalities but there are no adequate human studies 3
Critical Safety Data on Triptans
What the Evidence Shows
- No clear teratogenic signal has been identified in available human data for triptans 2, 4, 5
- A Swedish registry study of 3,286 women using triptans or ergots in early pregnancy found no increased risk for congenital malformations (OR 0.95; 95% CI 0.80-1.12) 4
- Current data are sufficient to rule out large increases in birth defects but cannot exclude small increases in risk 5
Known Pregnancy Risks
- Preterm birth rates appear elevated with triptan use (OR 1.50; 95% CI 1.22-1.84 when used later in pregnancy) 4
- Increased risk for pre-eclampsia (OR 1.44; 95% CI 1.17-1.76) in women using migraine medications 4
- Animal studies showed embryolethality and fetal vascular abnormalities at doses 2-3 times the maximum human dose 3
Long-Term Offspring Outcomes
- A Norwegian cohort study found no increased risk of ADHD diagnosis or symptoms in children with prenatal triptan exposure (weighted HR 1.16; 95% CI 0.78-1.74) 6
Medications That Are Absolutely Contraindicated
- Ergotamine derivatives and dihydroergotamine are contraindicated throughout pregnancy due to oxytocic properties that can harm the fetus 7, 1
- Opioids and butalbital-containing medications should be avoided due to risks of dependency, rebound headaches, and potential fetal harm 1
- Topiramate, candesartan, and sodium valproate are contraindicated due to adverse fetal effects 1
- CGRP antagonists (gepants) should be avoided due to insufficient safety data 1
Practical Clinical Approach
When to Consider Triptans
- Only after acetaminophen and (if in second trimester) NSAIDs have failed 1
- When migraine severity significantly impacts maternal quality of life and function
- Under specialist (neurologist or maternal-fetal medicine) supervision 1
Which Triptan to Choose
- Sumatriptan is the preferred triptan if any triptan must be used, as it has the most extensive safety data 1, 2, 5
- Use the lowest effective dose and limit frequency to prevent medication overuse headache 1
Adjunctive Treatment
- Metoclopramide 10 mg can be used safely for migraine-associated nausea, particularly in the second and third trimesters 1
Critical Pitfalls to Avoid
- Do not confuse the contraindication for ergots with the cautious use of triptans—ergots have oxytocic properties and are absolutely contraindicated, while triptans may be used sparingly under supervision 7, 1
- Limit acute treatment frequency to less than 10 days per month for triptans to prevent medication overuse headache 1
- Always counsel on lifestyle modifications first: adequate hydration, regular meals, consistent sleep patterns, and trigger avoidance 1
- Evaluate for preeclampsia urgently if a pregnant woman with hypertension develops new headache 1