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Pharmacological treatment of migraine during pregnancy and breastfeeding

This article has been updated

Key Points

  • Migraine affects up to one in four women of reproductive age, but migraine will often improve spontaneously during pregnancy

  • Nonpharmacological approaches should always be tried as first-line treatment for migraine during pregnancy

  • Several effective acute antimigraine medications are reasonably safe to use for pregnant and breastfeeding women

  • In pregnancy, preventive drug therapy should be considered only in the most severe migraine cases

  • Periconceptional counselling is important to promote a safe and healthy pregnancy and postpartum period for the mother and child

Abstract

Migraine affects up to 25% of women of reproductive age. In the majority of these women, migraine improves progressively during pregnancy, but symptoms generally recur shortly after delivery. As suboptimally treated migraine in pregnancy could have negative consequences for both mother and fetus, the primary aim of clinicians should be to provide optimal treatment according to stage of pregnancy, while minimising possible risks related to drug therapy. Nonpharmacological approaches are always first-line treatment, and should also be used to complement any required drug treatment. Paracetamol is the preferred drug for acute treatment throughout pregnancy. If paracetamol is not sufficiently effective, sporadic use of sumatriptan can be considered. NSAIDs such as ibuprofen can also be used under certain circumstances, though their intake in the first and third trimesters is associated with specific risks and contraindications. Preventive treatment should only be considered in the most severe cases. In women contemplating pregnancy, counselling is essential to promote a safe and healthy pregnancy and postpartum period for the mother and child, and should involve a dialogue addressing maternal concerns and expectations about drug treatment. This Review summarizes current evidence of the safety of the most common antimigraine medications during pregnancy and breastfeeding, and provides treatment recommendations for use in clinical practice.

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Figure 1: Algorithm for the treatment of migraine in pregnant women.

Change history

  • 19 March 2015

    In the section discussing treatment options during pregnancy, the last sentence under the subheading 'Antidepressants' should cite reference 83, not 84. The correction has been made to the print and online versions of the article.

  • 03 April 2015

    In the section discussing treatment options during pregnancy, subheadings 'Ergot alkaloids' and 'Antidepressants' should cite reference 25, not 23. In the section discussing treatment options during breastfeeding, subheading 'Paracetamol' and 'Opioid analgesics' should cite reference 24, not 21; subheading 'Ergot alkaloids' should cite reference 19, not 24. The corrections have been made to the print and online versions of the article.

References

  1. 1

    Stovner, L. J., Zwart, J. A., Hagen, K., Terwindt, G. M. & Pascual, J. Epidemiology of headache in Europe. Eur. J. Neurol. 13, 333–345 (2006).

    Article  CAS  Google Scholar 

  2. 2

    Lipton, R. B. et al. Migraine prevalence, disease burden, and the need for preventive therapy. Neurology 68, 343–349 (2007).

    Article  CAS  Google Scholar 

  3. 3

    Sacco, S., Ricci, S., Degan, D. & Carolei, A. Migraine in women: the role of hormones and their impact on vascular diseases. J. Headache Pain 13, 177–189 (2012).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  4. 4

    Sances, G. et al. Course of migraine during pregnancy and postpartum: a prospective study. Cephalalgia 23, 197–205 (2003).

    Article  CAS  Google Scholar 

  5. 5

    Maggioni, F., Alessi, C., Maggino, T. & Zanchin, G. Headache during pregnancy. Cephalalgia 17, 765–769 (1997).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  6. 6

    Nappi, R. E. et al. Headaches during pregnancy. Curr. Pain Headache Rep. 15, 289–294 (2011).

    Article  Google Scholar 

  7. 7

    Aube, M. Migraine in pregnancy. Neurology 53, S26–S28 (1999).

    CAS  PubMed  Google Scholar 

  8. 8

    Wright, G. D. & Patel, M. K. Focal migraine and pregnancy. Br. Med. J. (Clin. Res. Ed.) 293, 1557–1558 (1986).

    Article  CAS  Google Scholar 

  9. 9

    Hoshiyama, E. et al. Postpartum migraines: a long-term prospective study. Intern. Med. 51, 3119–3123 (2012).

    Article  Google Scholar 

  10. 10

    Kvisvik, E., Stovner, L., Helde, G., Bovim, G. & Linde, M. Headache and migraine during pregnancy and puerperium: the MIGRA-study. J. Headache Pain 12, 443–451 (2011).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  11. 11

    Contag, S. A. & Bushnell, C. Contemporary management of migrainous disorders in pregnancy. Curr. Opin. Obstet. Gynecol. 22, 437–445 (2010).

    Article  Google Scholar 

  12. 12

    Nezvalová-Henriksen, K., Spigset, O. & Nordeng, H. Maternal characteristics and migraine pharmacotherapy during pregnancy: cross-sectional analysis of data from a large cohort study. Cephalalgia 29, 1267–1276 (2009).

    Article  Google Scholar 

  13. 13

    Gladstone, J. P., Eross, E. J. & Dodick, D. W. Migraine in special populations. Treatment strategies for children and adolescents, pregnant women, and the elderly. Postgrad. Med. 115, 39–44, 47–50 (2004).

    Article  Google Scholar 

  14. 14

    Facchinetti, F. et al. Migraine is a risk factor for hypertensive disorders in pregnancy: a prospective cohort study. Cephalalgia 29, 286–292 (2009).

    Article  CAS  Google Scholar 

  15. 15

    Williams, M. A. et al. Trimester-specific blood pressure levels and hypertensive disorders among pregnant migraineurs. Headache 51, 1468–1482 (2011).

    Article  PubMed  PubMed Central  Google Scholar 

  16. 16

    Adeney, K. L. et al. Risk of preeclampsia in relation to maternal history of migraine headaches. J. Matern. Fetal Neonatal Med. 18, 167–172 (2005).

    Article  Google Scholar 

  17. 17

    Bushnell, C. D., Jamison, M. & James, A. H. Migraines during pregnancy linked to stroke and vascular diseases: US population based case-control study. BMJ 338, b664 (2009).

    Article  PubMed  PubMed Central  Google Scholar 

  18. 18

    Hauth, J. C. et al. Pregnancy outcomes in healthy nulliparas who developed hypertension. Calcium for Preeclampsia Prevention Study Group. Obstet. Gynecol. 95, 24–28 (2000).

    CAS  PubMed  Google Scholar 

  19. 19

    Briggs, G. G. & Freeman, R. K. (eds) Drugs in Pregnancy and Lactation: A Reference Guide to Fetal and Neonatal Risk 10th edn (Wolters Kluwer Health, 2014).

    Google Scholar 

  20. 20

    Thompson, J. M., Waldie, K. E., Wall, C. R., Murphy, R. & Mitchell, E. A. Associations between acetaminophen use during pregnancy and ADHD symptoms measured at ages 7 and 11 years. PLoS ONE 9, e108210 (2014).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  21. 21

    Brandlistuen, R. E., Ystrøm, E., Nulman, I., Koren, G. & Nordeng, H. Prenatal paracetamol exposure and child neurodevelopment: a sibling-controlled cohort study. Int. J. Epidemiol. 42, 1702–1713 (2013).

    Article  PubMed  PubMed Central  Google Scholar 

  22. 22

    Liew, Z., Ritz, B., Rebordosa, C., Lee, P. C. & Olsen, J. Acetaminophen use during pregnancy, behavioral problems, and hyperkinetic disorders. JAMA Pediatr. 168, 313–320 (2014).

    Article  PubMed  PubMed Central  Google Scholar 

  23. 23

    European Medicines Agency. Pharmacovigilance Risk Assessment Committee (PRAC): minutes of the meeting on 5–8 May 2014. PRAC: Agendas, minutes and highlights [online], (2014).

  24. 24

    Worthington, I. et al. Canadian Headache Society Guideline: acute drug therapy for migraine headache. Can. J. Neurol. Sci. 40, S1–S80 (2013).

    Article  Google Scholar 

  25. 25

    Evers, S. et al. EFNS guideline on the drug treatment of migraine—revised report of an EFNS task force. Eur. J. Neurol. 16, 968–981 (2009).

    Article  CAS  Google Scholar 

  26. 26

    Østensen, M. & Skomsvoll, J. Anti-inflammatory pharmacotherapy during pregnancy. Expert Opin. Pharmacother. 5, 571–580 (2004).

    Article  Google Scholar 

  27. 27

    Koren, G., Florescu, A., Costei, A. M., Boskovic, R. & Moretti, M. E. Nonsteroidal antiinflammatory drugs during third trimester and the risk of premature closure of the ductus arteriosus: a meta-analysis. Ann. Pharmacother. 40, 824–829 (2006).

    Article  CAS  Google Scholar 

  28. 28

    Insel, P. A. in Goodman and Gilman's The Pharmacological Basis of Therapeutics 9th edn Ch. 27 (eds Hardman, J. G. et al.) 617–657 (MacGraw–Hill, 1996).

    Google Scholar 

  29. 29

    Reese, J. et al. Coordinated regulation of fetal and maternal prostaglandins directs successful birth and postnatal adaptation in the mouse. Proc. Natl Acad. Sci. USA 97, 9759–9764 (2000).

    Article  CAS  Google Scholar 

  30. 30

    Li, D. K., Liu, L. & Odouli, R. Exposure to non-steroidal anti-inflammatory drugs during pregnancy and risk of miscarriage: population based cohort study. BMJ 327, 368 (2003).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  31. 31

    Nielsen, G. L., Sørensen, H. T., Larsen, H. & Pedersen, L. Risk of adverse birth outcome and miscarriage in pregnant users of non-steroidal anti-inflammatory drugs: population based observational study and case-control study. BMJ 322, 266–270 (2001).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  32. 32

    Nakhai-Pour, H. R., Broy, P., Sheehy, O. & Berard, A. Use of nonaspirin nonsteroidal anti-inflammatory drugs during pregnancy and the risk of spontaneous abortion. CMAJ 183, 1713–1720 (2011).

    Article  PubMed  PubMed Central  Google Scholar 

  33. 33

    Hernandez, R. K., Werler, M. M., Romitti, P., Sun, L. & Anderka, M. Nonsteroidal antiinflammatory drug use among women and the risk of birth defects. Am. J. Obstet. Gynecol. 206, 228.e1–228.e8 (2012).

    Article  CAS  Google Scholar 

  34. 34

    Ofori, B., Oraichi, D., Blais, L., Rey, E. & Berard, A. Risk of congenital anomalies in pregnant users of non-steroidal anti-inflammatory drugs: a nested case-control study. Birth Defects Res. B Dev. Reprod. Toxicol. 77, 268–279 (2006).

    Article  CAS  Google Scholar 

  35. 35

    Ericson, A. & Källén, B. A. Nonsteroidal anti-inflammatory drugs in early pregnancy. Reprod. Toxicol. 15, 371–375 (2001).

    Article  CAS  Google Scholar 

  36. 36

    Daniel, S. et al. Fetal exposure to nonsteroidal anti-inflammatory drugs and spontaneous abortions. CMAJ 186, E177–E182 (2014).

    Article  PubMed  PubMed Central  Google Scholar 

  37. 37

    Edwards, D. R. et al. Periconceptional over-the-counter nonsteroidal anti-inflammatory drug exposure and risk for spontaneous abortion. Obstet. Gynecol. 120, 113–122 (2012).

    Article  CAS  Google Scholar 

  38. 38

    Nielsen, G. L., Skriver, M. V., Pedersen, L. & Sørensen, H. T. Danish group reanalyses miscarriage in NSAID users. BMJ 328, 109 (2004).

    Article  PubMed  PubMed Central  Google Scholar 

  39. 39

    Cassina, M. et al. First trimester diclofenac exposure and pregnancy outcome. Reprod. Toxicol. 30, 401–404 (2010).

    Article  CAS  Google Scholar 

  40. 40

    Nezvalová-Henriksen, K., Spigset, O. & Nordeng, H. Effects of ibuprofen, diclofenac, naproxen, and piroxicam on the course of pregnancy and pregnancy outcome: a prospective cohort study. BJOG 120, 948–959 (2013).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  41. 41

    Daniel, S. et al. Major malformations following exposure to nonsteroidal antiinflammatory drugs during the first trimester of pregnancy. J. Rheumatol. 39, 2163–2169 (2012).

    Article  CAS  Google Scholar 

  42. 42

    van Gelder, M. M., Roeleveld, N. & Nordeng, H. Exposure to non-steroidal anti-inflammatory drugs during pregnancy and the risk of selected birth defects: a prospective cohort study. PLoS ONE 6, e22174 (2011).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  43. 43

    Cleves, M. A. et al. Maternal use of acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs), and muscular ventricular septal defects. Birth Defects Res. A Clin. Mol. Teratol 70, 107–113 (2004).

    Article  CAS  Google Scholar 

  44. 44

    Jensen, M. S. et al. Maternal use of acetaminophen, ibuprofen, and acetylsalicylic acid during pregnancy and risk of cryptorchidism. Epidemiology 21, 779–785 (2010).

    Article  Google Scholar 

  45. 45

    Norton, M. E., Merrill, J., Cooper, B. A., Kuller, J. A. & Clyman, R. I. Neonatal complications after the administration of indomethacin for preterm labor. N. Engl. J. Med. 329, 1602–1607 (1993).

    Article  CAS  Google Scholar 

  46. 46

    Vermillion, S. T., Scardo, J. A., Lashus, A. G. & Wiles, H. B. The effect of indomethacin tocolysis on fetal ductus arteriosus constriction with advancing gestational age. Am. J. Obstet. Gynecol. 177, 256–259; discussion 259–261 (1997).

    Article  CAS  Google Scholar 

  47. 47

    Ojala, R., Ikonen, S. & Tammela, O. Perinatal indomethacin treatment and neonatal complications in preterm infants. Eur. J. Pediatr. 159, 153–155 (2000).

    Article  CAS  Google Scholar 

  48. 48

    Doyle, N. M., Gardner, M. O., Wells, L., Qualls, C. & Papile, L. A. Outcome of very low birth weight infants exposed to antenatal indomethacin for tocolysis. J. Perinatol. 25, 336–340 (2005).

    Article  CAS  Google Scholar 

  49. 49

    Ojala, R. et al. Renal follow up of premature infants with and without perinatal indomethacin exposure. Arch. Dis. Child. Fetal Neonatal Ed. 84, F28–F33 (2001).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  50. 50

    Benini, D., Fanos, V., Cuzzolin, L. & Tato, L. In utero exposure to nonsteroidal anti-inflammatory drugs: neonatal renal failure. Pediatr. Nephrol. 19, 232–234 (2004).

    Article  Google Scholar 

  51. 51

    Phadke, V., Bhardwaj, S., Sahoo, B. & Kanhere, S. Maternal ingestion of diclofenac leading to renal failure in newborns. Pediatr. Nephrol. 27, 1033–1036 (2012).

    Article  Google Scholar 

  52. 52

    Alano, M. A., Ngougmna, E., Ostrea, E. M. Jr & Konduri, G. G. Analysis of nonsteroidal antiinflammatory drugs in meconium and its relation to persistent pulmonary hypertension of the newborn. Pediatrics 107, 519–523 (2001).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  53. 53

    Van Marter, L. J., Hernandez-Diaz, S., Werler, M. M., Louik, C. & Mitchell, A. A. Nonsteroidal antiinflammatory drugs in late pregnancy and persistent pulmonary hypertension of the newborn. Pediatrics 131, 79–87 (2013).

    Article  PubMed  PubMed Central  Google Scholar 

  54. 54

    Tyler, C. P. et al. Brain damage in preterm newborns and maternal medication: the ELGAN Study. Am. J. Obstet. Gynecol. 207, 192.e1–192.e9 (2012).

    Article  Google Scholar 

  55. 55

    Provost, M., Eaton, J. L. & Clowse, M. E. Fertility and infertility in rheumatoid arthritis. Curr. Opin. Rheumatol 26, 308–314 (2014).

    Article  Google Scholar 

  56. 56

    Soldin, O. P., Dahlin, J. & O'Mara, D. M. Triptans in pregnancy. Ther. Drug Monit. 30, 5–9 (2008).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  57. 57

    Gupta, S. et al. Functional reactivity of 5-HT receptors in human umbilical cord and maternal subcutaneous fat arteries after normotensive or pre-eclamptic pregnancy. J. Hypertens. 24, 1345–1353 (2006).

    Article  CAS  Google Scholar 

  58. 58

    Bonnin, A. & Levitt, P. Fetal, maternal, and placental sources of serotonin and new implications for developmental programming of the brain. Neuroscience 197, 1–7 (2011).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  59. 59

    Ephross, S. A. & Sinclair, S. M. Final results from the 16-year sumatriptan, naratriptan, and treximet pregnancy registry. Headache 54, 1158–1172 (2014).

    Article  Google Scholar 

  60. 60

    Nezvalová-Henriksen, K., Spigset, O. & Nordeng, H. Triptan safety during pregnancy: a Norwegian population registry study. Eur. J. Epidemiol. 28, 759–769 (2013).

    Article  Google Scholar 

  61. 61

    Berard, A. & Kori, S. Dihydroergotamine (DHE) use during gestation and the risk of adverse pregnancy outcomes. Headache 52, 1085–1093 (2012).

    Article  Google Scholar 

  62. 62

    Merck & Co. Thirteenth/Fourteenth Annual Report from the Merck Pregnancy Registry for MAXALT (rizatriptan benzoate): covering the period from approval (June 1998) through June 12, 2012. Merck Pregnancy Registries [online], (2012).

  63. 63

    Källén, B., Nilsson, E. & Otterblad Olausson, P. Delivery outcome after maternal use of drugs for migraine: a register study in Sweden. Drug Saf. 34, 691–703 (2011).

    Article  Google Scholar 

  64. 64

    Nezvalová-Henriksen, K., Spigset, O. & Nordeng, H. Triptan exposure during pregnancy and the risk of major congenital malformations and adverse pregnancy outcomes: results from the Norwegian Mother and Child. Cohort Study. Headache 50, 563–575 (2010).

    Article  Google Scholar 

  65. 65

    Källén, B. & Lygner, P. E. Delivery outcome in women who used drugs for migraine during pregnancy with special reference to sumatriptan. Headache 41, 351–356 (2001).

    Article  Google Scholar 

  66. 66

    Olesen, C., Steffensen, F. H., Sørensen, H. T., Nielsen, G. L. & Olsen, J. Pregnancy outcome following prescription for sumatriptan. Headache 40, 20–24 (2000).

    Article  CAS  Google Scholar 

  67. 67

    O'Quinn, S. et al. Pregnancy and perinatal outcomes in migraineurs using sumatriptan: a prospective study. Arch. Gynecol. Obstet. 263, 7–12 (1999).

    Article  CAS  Google Scholar 

  68. 68

    Shuhaiber, S. B. et al. Pregnancy outcome following first trimester exposure to sumatriptan. Neurology 51, 581–583 (1998).

    Article  CAS  Google Scholar 

  69. 69

    Nezvalová-Henriksen, K., Spigset, O. & Nordeng, H. M. Triptan exposure during pregnancy and the risk of major congenital malformations and adverse pregnancy outcomes: results from the Norwegian Mother and Child Cohort Study [erratum]. Headache 52, 1319–1320 (2012).

    Article  Google Scholar 

  70. 70

    Broussard, C. S. et al. Maternal treatment with opioid analgesics and risk for birth defects. Am. J. Obstet. Gynecol. 204, 314.e1–314.e11 (2011).

    Article  CAS  Google Scholar 

  71. 71

    Nezvalová-Henriksen, K., Spigset, O. & Nordeng, H. Effects of codeine on pregnancy outcome: results from a large population-based cohort study [erratum]. Eur. J. Clin. Pharmacol. 68, 1689–1690 (2012).

    Article  Google Scholar 

  72. 72

    Cassina, M., Di Gianantonio, E., Toldo, I., Battistella, P. A. & Clementi, M. Migraine therapy during pregnancy and lactation. Expert Opin. Drug Saf. 9, 937–948 (2010).

    Article  Google Scholar 

  73. 73

    Banhidy, F., Acs, N., Puho, E. & Czeizel, A. E. Ergotamine treatment during pregnancy and a higher rate of low birthweight and preterm birth. Br. J. Clin. Pharmacol. 64, 510–516 (2007).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  74. 74

    Schulman, E. A. & Dermott, K. F. Sumatriptan plus metoclopramide in triptan-nonresponsive migraineurs. Headache 43, 729–733 (2003).

    Article  Google Scholar 

  75. 75

    MacGregor, E. A. Anti-emetics. Curr. Med. Res. Opin. 17 (Suppl. 1), S22–S25 (2001).

    Article  Google Scholar 

  76. 76

    Pasternak, B., Svanstrom, H., Molgaard-Nielsen, D., Melbye, M. & Hviid, A. Metoclopramide in pregnancy and risk of major congenital malformations and fetal death. JAMA 310, 1601–1611 (2013).

    Article  CAS  Google Scholar 

  77. 77

    [No authors listed] Domperidone: QT prolongation in infants. Prescrire Int. 20, 14 (2011).

  78. 78

    Holland, S. et al. Evidence-based guideline update: NSAIDs and other complementary treatments for episodic migraine prevention in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology 78, 1346–1353 (2012).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  79. 79

    Silberstein, S. D. et al. Evidence-based guideline update: pharmacologic treatment for episodic migraine prevention in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology 78, 1337–1345 (2012).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  80. 80

    Yakoob, M. Y. et al. The risk of congenital malformations associated with exposure to beta-blockers early in pregnancy: a meta-analysis. Hypertension 62, 375–381 (2013).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  81. 81

    Bateman, B. T. et al. Chronic hypertension in pregnancy and the risk of congenital malformations: a cohort study. Am. J. Obstet. Gynecol. 212, 337.e1–337.e14.

  82. 82

    MacGregor, E. A. Headache in pregnancy. Continuum (Minneap. Minn.) 20, 128–147 (2014).

    Google Scholar 

  83. 83

    Wadelius, M., Darj, E., Frenne, G. & Rane, A. Induction of CYP2D6 in pregnancy. Clin. Pharmacol. Ther. 62, 400–407 (1997).

    Article  CAS  Google Scholar 

  84. 84

    Meador, K. J. et al. Fetal antiepileptic drug exposure and cognitive outcomes at age 6 years (NEAD study): a prospective observational study. Lancet Neurol. 12, 244–252 (2013).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  85. 85

    Christensen, J. et al. Prenatal valproate exposure and risk of autism spectrum disorders and childhood autism. JAMA 309, 1696–1703 (2013).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  86. 86

    Banach, R., Boskovic, R., Einarson, T. & Koren, G. Long-term developmental outcome of children of women with epilepsy, unexposed or exposed prenatally to antiepileptic drugs: a meta-analysis of cohort studies. Drug Saf. 33, 73–79 (2010).

    Article  CAS  Google Scholar 

  87. 87

    European Medicines Agency. CMDh agrees to strengthen warnings on the use of valproate medicines in women and girls. European Medicines Agency news and press release archive [online], (2014).

  88. 88

    Mines, D. et al. Topiramate use in pregnancy and the birth prevalence of oral clefts. Pharmacoepidemiol. Drug Saf. 23, 1017–1025 (2014).

    Article  CAS  Google Scholar 

  89. 89

    Margulis, A. V. et al. Use of topiramate in pregnancy and risk of oral clefts. Am. J. Obstet. Gynecol. 207, 405.e1–405.e7 (2012).

    Article  CAS  Google Scholar 

  90. 90

    Hernandez-Diaz, S. et al. Association between topiramate and zonisamide use during pregnancy and low birth weight. Obstet. Gynecol. 123, 21–28 (2014).

    Article  CAS  Google Scholar 

  91. 91

    Palmsten, K. et al. Antidepressant use and risk for preeclampsia. Epidemiology 24, 682–691 (2013).

    Article  PubMed  PubMed Central  Google Scholar 

  92. 92

    Källén, B. Neonate characteristics after maternal use of antidepressants in late pregnancy. Arch. Pediatr. Adolesc. Med. 158, 312–316 (2004).

    Article  Google Scholar 

  93. 93

    Pringsheim, T. et al. Canadian Headache Society guideline for migraine prophylaxis. Can. J. Neurol. Sci. 39 (Suppl. 2), S1–S59 (2012).

    PubMed  Google Scholar 

  94. 94

    [No authors listed] ACE inhibitors, angiotensin II receptor blockers and pregnancy: fetal renal impairment. Prescrire Int. 22, 243 (2013).

  95. 95

    Bullo, M., Tschumi, S., Bucher, B. S., Bianchetti, M. G. & Simonetti, G. D. Pregnancy outcome following exposure to angiotensin-converting enzyme inhibitors or angiotensin receptor antagonists: a systematic review. Hypertension 60, 444–450 (2012).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  96. 96

    Cooper, W. O. et al. Major congenital malformations after first-trimester exposure to ACE inhibitors. N. Engl. J. Med. 354, 2443–2451 (2006).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  97. 97

    Tan, M., Kim, E., Koren, G. & Bozzo, P. Botulinum toxin type A in pregnancy. Can. Fam. Physician 59, 1183–1184 (2013).

    PubMed  PubMed Central  Google Scholar 

  98. 98

    Robinson, A. Y. & Grogan, P. M. OnabotulinumtoxinA successfully used as migraine prophylaxis during pregnancy: a case report. Mil. Med. 179, e703–e704 (2014).

    Article  Google Scholar 

  99. 99

    Doyle, L. W., Anderson, P. J., Haslam, R., Lee, K. J. & Crowther, C. School-age outcomes of very preterm infants after antenatal treatment with magnesium sulfate vs placebo. JAMA 312, 1105–1113 (2014).

    Article  CAS  Google Scholar 

  100. 100

    Gartner, L. M. et al. Breastfeeding and the use of human milk. Pediatrics 115, 496–506 (2005).

    Article  Google Scholar 

  101. 101

    Hale, T. W. (ed.) Medications and Mothers' Milk: A Manual of Lactational Pharmacology 16th edn (Hale Publishing, 2014).

    Google Scholar 

  102. 102

    Bitzen, P. O., Gustafsson, B., Jostell, K. G., Melander, A. & Wahlin-Boll, E. Excretion of paracetamol in human breast milk. Eur. J. Clin. Pharmacol. 20, 123–125 (1981).

    Article  CAS  Google Scholar 

  103. 103

    Spigset, O. & Hägg, S. Analgesics and breast-feeding: safety considerations. Paediatr. Drugs 2, 223–238 (2000).

    Article  CAS  Google Scholar 

  104. 104

    Matheson, I., Lunde, P. K. & Notarianni, L. Infant rash caused by paracetamol in breast milk? Pediatrics 76, 651–652 (1985).

    CAS  PubMed  Google Scholar 

  105. 105

    Davanzo, R., Bua, J., Paloni, G. & Facchina, G. Breastfeeding and migraine drugs. Eur. J. Clin. Pharmacol. 70, 1313–1324 (2014).

    Article  CAS  Google Scholar 

  106. 106

    Terragna, A. & Spirito, L. Thrombocytopenic purpura in an infant after administration of acetylsalicylic acid to the wet-nurse. Minerva Pediatr. 19, 613–616 (1967).

    CAS  PubMed  Google Scholar 

  107. 107

    Wojnar-Horton, R. E. et al. Distribution and excretion of sumatriptan in human milk. Br. J. Clin. Pharmacol. 41, 217–221 (1996).

    Article  CAS  Google Scholar 

  108. 108

    U. S. Food and Drug Administration. Label information Imitrex. Drugs @ FDA: FDA approved drug products [online], (2013).

  109. 109

    David, P., Kling, J. & Starling, A. Migraine in pregnancy and lactation. Curr. Neurol. Neurosci. Rep. 14, 1–6 (2014).

    Article  CAS  Google Scholar 

  110. 110

    Koren, G., Cairns, J., Chitayat, D., Gaedigk, A. & Leeder, S. J. Pharmacogenetics of morphine poisoning in a breastfed neonate of a codeine-prescribed mother. Lancet 368, 704 (2006).

    Article  Google Scholar 

  111. 111

    Madadi, P. et al. Guidelines for maternal codeine use during breastfeeding. Can. Fam. Physician 55, 1077–1078 (2009).

    PubMed  PubMed Central  Google Scholar 

  112. 112

    Hendrickson, R. G. & McKeown, N. J. Is maternal opioid use hazardous to breast-fed infants? Clin. Toxicol. (Phila.) 50, 1–14 (2012).

    Article  CAS  Google Scholar 

  113. 113

    Kauppila, A. et al. Metoclopramide and breast feeding: transfer into milk and the newborn. Eur. J. Clin. Pharmacol. 25, 819–823 (1983).

    Article  CAS  Google Scholar 

  114. 114

    Bauer, J. H., Pape, B., Zajicek, J. & Groshong, T. Propranolol in human plasma and breast milk. Am. J. Cardiol. 43, 860–862 (1979).

    Article  CAS  Google Scholar 

  115. 115

    Sandström, B. & Regårdh, C. G. Metoprolol excretion into breast milk. Br. J. Clin. Pharmacol. 9, 518–519 (1980).

    Article  PubMed  PubMed Central  Google Scholar 

  116. 116

    Kulas, J., Lunell, N. O., Rosing, U., Steen, B. & Rane, A. Atenolol and metoprolol. A comparison of their excretion into human breast milk. Acta Obstet. Gynecol. Scand. Suppl. 118, 65–69 (1984).

    Article  CAS  Google Scholar 

  117. 117

    Shannon, M. E., Malecha, S. E. & Cha, A. J. Beta blockers and lactation: an update. J. Hum. Lact. 16, 240–245 (2000).

    Article  CAS  Google Scholar 

  118. 118

    Hägg, S. & Spigset, O. Anticonvulsant use during lactation. Drug Saf. 22, 425–440 (2000).

    Article  Google Scholar 

  119. 119

    Öhman, I., Vitols, S., Luef, G., Söderfeldt, B. & Tomson, T. Topiramate kinetics during delivery, lactation, and in the neonate: preliminary observations. Epilepsia 43, 1157–1160 (2002).

    Article  Google Scholar 

  120. 120

    Spigset, O. & Hägg, S. Excretion of psychotropic drugs into breast milk. CNS Drugs 9, 111–134 (1998).

    Article  CAS  Google Scholar 

  121. 121

    Cruikshank, D. P., Varner, M. W. & Pitkin, R. M. Breast milk magnesium and calcium concentrations following magnesium sulfate treatment. Am. J. Obstet. Gynecol. 143, 685–688 (1982).

    Article  CAS  Google Scholar 

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O.S., S.A., H.N. and K.N.-H. wrote the article. All authors researched data for the article, provided substantial contribution to discussion of content and reviewed/edited manuscript before submission.

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Correspondence to Olav Spigset.

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L.J.S. has received a speaker's fee from GlaxoSmithKline. The other authors declare no competing interests.

Supplementary information

Supplementary Table 1

Overview of observational studies on associations of NSAID exposure in the first trimester and miscarriage and congenital malformations (DOCX 44 kb)

Supplementary Table 2

Overview of observational studies on associations of NSAID exposure in the second and/or third trimester and other pregnancy outcomes (DOCX 31 kb)

Supplementary Table 3

Overview of observational studies on associations of triptan exposure during pregnancy and adverse pregnancy outcomes (DOCX 34 kb)

Supplementary further reading

Recommended resources on safety of medications during pregnancy and lactation (DOCX 22 kb)

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Amundsen, S., Nordeng, H., Nezvalová-Henriksen, K. et al. Pharmacological treatment of migraine during pregnancy and breastfeeding. Nat Rev Neurol 11, 209–219 (2015). https://doi.org/10.1038/nrneurol.2015.29

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