Use of common migraine treatments in breast-feeding women: a summary of recommendations.

BACKGROUND Breast-feeding has important health and emotional benefits for both mother and infant, and should be encouraged. While there are some data to suggest migraine may improve during breast-feeding, more than half of women experience migraine recurrence with 1 month of delivery. Thus, a thorough knowledge base of the safety and recommended use of common acute and preventive migraine drugs during breast-feeding is vital to clinicians treating migraine sufferers. Choice of treatment should take into account the balance of benefit and risk of medication. For some of the medications commonly used during breast-feeding, there is not good evidence about benefits. METHODS A list of commonly used migraine medications was agreed upon by the 6 authors, who treat migraine and other headaches on a regular basis and are members of the Women's Special Interest Section of the American Headache Society. Each medication was researched by the first author utilizing widely accepted data sources, such as the American Academy of Pediatrics publication "The Transfer of Drugs and Other Chemicals Into Human Milk; Thomas Hale's manual Medications and Mothers Milk; Briggs, Freeman, and Yaffe's reference book Drugs in Pregnancy and Lactation; and the National Library of Medicine's Drugs and Lactation Database (LactMed) - a peer-reviewed and fully referenced database available online. RESULTS Many commonly used migraine medications may be compatible with breast-feeding based on expert recommendations. Ibuprofen, diclofenac, and eletriptan are among acute medications with low levels in breast milk, but studies of triptans are limited. Toxicity is a concern with aspirin due to an association with Reye's syndrome; sedation or apnea is a concern with opioids. Finally, preventive medications not recommended include zonisamide, atenolol, and tizanidine. CONCLUSIONS Several excellent resources are available for clinicians making treatment decisions in breast-feeding women. Clinicians treating migraine should discuss both acute and preventive treatment options shortly before and within a few months after delivery, keeping in mind the clinical features of the individual patient, and in consultation with their obstetrician and pediatrician. An awareness of the pharmacological data that are currently available and how to access that data may be helpful in making treatment decisions in this population.