Triptans for migraine in special populations: migraine during pregnancy and lactation

The peak prevalence of migraine occurs during a woman's reproductive years, and although a majority of pregnant women may experience improvement in migraine frequency and severity, many do not. Additionally, the majority of pregnancies are unplanned, with the possibility that migraine treatment occurs during early pregnancy. Therefore, migraine treatment strategies during pregnancy should be discussed with women of child-bearing age even before pregnancy is considered. Drugs to avoid include those in US FDA rating scales D and X, and those in category C should be reviewed for their potential risks to the fetus versus benefit to a pregnant woman with migraine. Triptans are rated category C and are considered a relative contraindication on package inserts of these drugs. There are human placental transport studies of sumatriptan as well as serotonin receptor development studies suggesting that the effects of triptans on the fetus are slight. Although triptan pharmacokinetics may change during pregnancy, clinical significance is minimal in most cases. The use of triptans in human pregnancy has been reviewed through birth registry data and large cohort studies suggesting no significant association between triptan therapy and major congenital malformation or other adverse pregnancy outcome. Discussion of acute migraine treatment during pregnancy should include the potential use of triptans for moderate to severe pain or significant disability or pain that is rapidly escalating. The American Academy of Pediatrics rates triptan use as compatible with breastfeeding. Migraine is three-times more common in women than in men with peak prevalence occurring during a woman's reproductive years. By 41 years of age, 27% of women experience episodic moderate-to-severe headache [1]. Although most studies of migraine during pregnancy have shown that the majority of women report a decrease in frequency and intensity of their headache [2,3] and may continue to improve significantly towards the end of pregnancy [3], some women will not change or worsen. Only approximately 7% of women note the onset of migraine during pregnancy [4]. If headaches have not improved by the end of the first trimester, they are less likely to do so.