Are Triptans Safe To Take During Pregnancy?
Are Triptans Safe To Take During Pregnancy
Since 1990 Triptans are the best acute therapy drugs for treating migraine. There currently are 7 triptan drugs in the United States. When taken early in the course of a migraine headache 80 % of patients may be headache free in 2 hours. Triptans block the release of the inflammatory neurochemicals during the migraine process but must be taken early in the course of headache development. Triptans should be taken at the onset of the migraine headache.
Triptans should not be used with a personal or strong family history of coronary artery disease. They shouldn’t be used with uncontrolled hypertension. Doses should be limited for children, the elderly (defined here as over 65 years old.), and patients with basilar artery or complicated migraine (aura symptoms over 60 minutes.) Also, triptans should not be mixed with ergotamine or DHE within 24 hours.
Common triptan side effects.
Side effects may be--chest tightness or pressure, near fainting, neck/back pain which may be burning, a warm or hot feeling, dizziness, or drowsiness.
Oral tablet PO 50-100 mg
Nasal Spray 5-20 mg
Oral tab ZMT 2.5-5 mg
Nasal Spray 5 mg
Maxalt (rizatriptan) 10-20 mg
Axert (almotriptan) 6.25-12.5 mg
Relpax (eletriptan) 40 mg
Amerge (naratriptan) 2.5 mg
Frova (frovatriptan) 2.5 mg
These side effects are not serious and are usually related to activation of the autonomic nervous system which can cause contraction of smooth muscle in the chest resulting in tightness, or neck and back pain. Adrenalin release may cause a warm/hot feeling or dizziness.
The important point about the side effects are that they are not serious, and they are dose related. For example, a person using the common 100 mg sumatriptan tablet may develop chest tightness, but if they break the tablet in half and use 50 mg, many times the side effect doesn’t occur, and the lowered dose may effectively treat the migraine.
The first triptan to come out was injectable Imitrex (sumatriptan) 6 mg subcutaneously which is still the best, the strongest, and the fastest dose for treating migraine, but the next dose released was the 25 mg oral tablet which had an indication at first for treating adults, but now would be considered to be a pediatric dose.
The other point to be considered here is that the headache literature says that changing to another triptan is successful 60% of the time. So, if a patient develops a side effect with sumatriptan, rizatriptan may work well with no side effects.
There are 4 steps in the migraine process which I like to call the migraine timing cycle. The first step is trigeminal inflammation by the brainstem. Then the second step at 20-40 minutes the ganglion of the nerve and artery in the brain start to release the Neuropeptides: Neurokinin A, Substance P, and CGRP. Then at about 2 hours the release of these chemicals causes the 3rd step--meningeal artery vasodilatation, and the 4th step at 3-4 hours inflammation of the thalamus, a deep nucleus in the center of the brain which is called the “pain center” of the brain. The 4th step is also called “Central Sensitization” because steps 1,2, and 3 occur in the skull but are outside the brain (trigeminal nerve, nerve and arterial ganglions, cerebral arteries.) Step 4 inflames the thalamus, a deep nucleus inside the brain.
Migraine is defined by the International Classification of Headache as lasting 4-72 hours and this is done not for some trivial, abstract, academic reason using 3 days or 72 hours as the time a migraine may last, but rather because that’s how long these inflammatory neuropeptides stay in the body. They come into the brain, drain down the veins to the liver, and are discharged in the toilet after 3 days. If one treats migraine with over-the-counter drugs like Advil or Tylenol, they don’t stop the release of the neuropeptides and the inflammation, yet triptans will do that and that’s why they are such important and effective drugs for treating migraine.
Patients with migraine should treat with triptans but never with opiate drugs or drugs with butalbital, like Fioricet. Butalbital is a barbiturate drugs and is, in my opinion, the worse drug in the world that causes medication overuse headache. It has been banned in every country in the world except in Canada and the United States. The use of these this drug in America is a political issue to be resolved with legislators and so far, neurologists and headache doctors have not been successful getting legislators to eliminate the use of it.
Caffeine, Tylenol, Advil, Aleve, and triptans can cause medication overuse headache if taken too much. The general rule of migraine patients to prevent medication overuse headache is to limit over-the-counter painkillers and triptans to no more than 2 days a month. Medication overuse headache is the current term for persons who have chronic migraine from overuse of medication. It used to be called rebound headache which is an old term. Chronic migraine is defined by the International Classification of Headache as being 15 headaches or more per month, 8 of which have migraine features. Episodic headache is defined as 14 or less headache days per month.
If the patient uses over-the-counter medications or a triptan, a transition occurs so that after several migraine headaches have occurred within a week or 2, every time the patient takes caffeine or Tylenol or a triptan, the inflammatory neurochemicals are released and they stay in the body for 3 more days and so the migraine process becomes continuous. It is sort of like putting lighter fluid on a fire which makes the fire continue to burn. If one considers that migraine can generate chemicals that last 3 days and multiple that by 2 days, the result may be 6 days of neurochemical release per week. So, if the doctor allowed his patient to take Tylenol or a triptan 3 days a week that’s 9 days with chemical inflammation, more than the 7 days in a week, and explains the limitation of all painkillers and triptans to no more than 2 days a week.
I have a more thorough discussion of the migraine timing cycle on my webpage at www.doctormigraine.com/blog/categories/general migraine. However, this timing cycle points to the reason why migraine should be treated early with a triptan. The patient has only 20-40 minutes after the onset of pain before the neurochemicals are released and a triptan drug will block the release of these chemicals. It’s just that simple. Most patients don’t know to treat early and therefore the chemicals are released and inflame the trigeminal nerve, the arteries, and the thalamus. The patient returns and states that the triptan doesn’t work. It is reported that triptans well help migraine headache any time during a migraine, even if is treated late, but unless migraine is treated at onset, the patient will not be headache free within 2 hours.
Headache free means that all migraine symptoms are gone: headache, nausea, sound sensitivity, light sensitivity, olfactory sensitivity, mental cloudiness. In my office I go over and over again this point with patients to treat early and then the next time they in they report that they did well with the triptan, and the migraine was gone early. Many patients tell me that they get relief within 15 or 30 minutes, which is less than the reported time it takes the drug
Are Triptans Safe To Take During Pregnancy? Yes, Triptans have been studied extensively during pregnancy and the answer is that triptans are safe to take during pregnancy. They have no major teratogenic (baby harming) effects. Most of the data was obtained using sumatriptan.
Information regarding sumatriptan is the most abundant because it was the first triptan of all the 7 triptans now available, it has been available for many years, and sumatriptan is the best insurance covered drug of all the triptans. The price is right. Pregnancy registry data are available for 3 triptans: sumatriptan, naratriptan, and rizatriptan.
Are there reliable research articles showing that triptans are safe during pregnancy?
1. Schaefer, et al, published “Pregnancy outcome after anti-migraine triptan use: A prospective observational cohort study” in Cephalalgia in 2018. This article was highlighted at the American Headache Society meeting in 2017.
David Dodick MD, the former editor of Cephalagia and a professor of neurology at the Mayo Clinic in Scottsdale said regarding the Schaefer article, "There has been some mixed literature suggesting that triptans can cause low birthweight infants, spontaneous abortion and preterm labor, but at least in this study, which was a carefully conducted, prospective study, there was no evidence of that."
It is common to use triptans in women who are of childbearing age, and since 50 % of pregnancies are unplanned, fetal exposure to triptans is common.
2. Elizabeth W. Loder, MD, MPH, associate professor of neurology at Harvard Medical School and chief, Division of Headache and Pain in the Department of Neurology at Brigham and Women's Hospital, Boston, Massachusetts, who moderated the session, said the Schaefer, et al, findings were reassuring — with some caveats.
"It is nice to see yet another study that provides information on the safety of triptans when used during pregnancy," Dr. Loder told Medscape Medical News. "The point estimate for fetal malformations following pregnancy exposure was not elevated, although the confidence interval is wide and some elevation of risk cannot be completely excluded based on this study alone," she noted.
However, data from other sources are consistent with the finding, Dr Loder said. "For example, the sumatriptan pregnancy registry that was maintained by Glaxo following the introduction of sumatriptan likewise did not show any strong signal of teratogenicity, although again the confidence interval could not completely exclude some elevation in risk," she said.
"Taken as a whole, this is good news for women who need to treat severe migraine during pregnancy."
3.Marchenko, et al, reported in Headache in 2015 on “Pregnancy outcome following prenatal exposure to triptan medications: a meta-analysis.” Marchenko, et al, found that:
“The use of triptans during pregnancy does not appear to increase rates for major congenital malformations (MCM) or prematurity, but may increase rates of spontaneous miscarriage, according to a meta-analysis of 6 studies including 4,208 triptan-exposed pregnancies and 1.5 million controls. Compared with women with migraine who did not use triptans during pregnancy, triptan use was not associated with increased rates for MCM, prematurity, or miscarriage.”
4.As of this date (062119), three published prospective comparative studies confirmed there was no increased risk of major malformations reported with exposure to sumatriptan during pregnancy.
Also, two subsequent systematic reviews also found no association between teratogenicity and use of sumatriptan during pregnancy. A large Norwegian Mother and Child Cohort Study evaluated fetal outcomes following exposure to triptans during pregnancy. The authors identified 1535 pregnant women who received triptans during their pregnancies; 90% of the women used triptans in the first trimester and 65% used them during the second or third trimesters.
How should pregnant women first treat their migraines?
1. Nonpharmacologic measures should be tried first because they usually work and their effects on the pregnancy are benign. These measures include:
Adequate sleep duration
Use of ice packs on the head, neck, and shoulders
Avoidance of known migraine triggers such as heat, stress, sleep deprivation, missed meals, and strong odors.
2.Simple pharmacologic treatment
This is usually the use of Tylenol (acetaminophen) which is the initial preferred drug because of its lack of teratogenic effects and general OB doctor approval.
However, it may not be effective ,and it is less risky to use a triptan during a migraine than to have a pregnant woman who is nauseated, repeatedly vomits for days, becomes dehydrated, and deconditioned by long stays in bed with severe migraine and sensitivity to light and sound.
Therefore, many women with severe migraine are treated with triptans during pregnancy because they are the best drugs for acute therapy for migraine.
Good luck with this.
Britt Talley Daniel MD