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Avoid Triptans for Migraine in Pregnant Patients.

RANCHO MIRAGE, CALIF. -- The triptans are best avoided for treating migraines during pregnancy, Dr. Dawn A. Marcus advised at a meeting on treating the difficult headache patient.

So far, these serotonin agonists have not been associated with teratogenic effects in humans, but the accumulated safety data are still scanty, said Dr. Marcus, director of the Multidisciplinary Headache Clinic at the University of Pittsburgh.

The triptans have not specifically been tested for safety during pregnancy, but the manufacturers have established postmarketing registries of women who used the agents during pregnancy.

The largest series so far contains data on sumatriptan use in 222 pregnancies, of which 207 involved first-trimester use.

The rate of birth defects was 3.8%, similar to that observed in the general population (Headache 39[suppl.]:354, 1999).

"This can be comforting to women who inadvertently take triptans during pregnancy, but this report involved only 222 pregnancies. It's not a huge number, so exercise caution. Currently, I would not advise my patients to use triptans in pregnancy," Dr. Marcus commented at the meeting which was sponsored by the Diamond Headache Clinic.

Subcutaneous sumatripran can be safely used by lactating women as long as the patient expresses and discards the milk during the 4 hours after injection and bottle feeds until the next feeding, she added.

The triptans are currently rated by the Food and Drug Administration as Category C agents. This means that animal studies show the agents carry possible adverse effects to the fetus, and that the agents should be used only if the potential benefits outweigh any potential risks.

Dr. Marcus noted that at least half of women find their migraines improve during pregnancy.

But if headaches don't improve by the end of the first trimester, chances are they won't get better as the pregnancy progresses.

"Taking a wait-and-see approach is not a good option," she said.

She gave the following tips on treating migraines in pregnant patients:

* The safest medications for acute headache during pregnancy are acetaminophen, butalbiral, antinausea medications, and opioids excluding codeine.

* In addition to the triptans, aspirin, ergotamines, and isometheptene should be avoided.

* Use of acute care medicines should be restricted to 2-3 days a week to avoid rebound headaches. If patients have headaches more frequently they are best put on prophylactic medication.

* [beta]-Blockers and paroxetine are effective prophylactic agents that are safe throughout pregnancy.

* Gabapentin is a safe prophylactic agent early in pregnancy and may be a good option in patients trying to conceive. It should be discontinued later in pregnancy because it may delay bony ossification.

* Tricyclic antidepressants and valproate should be avoided in the first trimester.

* The safety of the calcium channel blockers, which are common prophylactic agents in nonpregnant patients, is unknown in pregnancy.

* Relaxation and biofeedback can be helpful in 80% of motivated patients. They are particularly good approaches for the pregnant patient.

* Restrictive diets are not advisable during pregnancy because they are unlikely to improve the headaches and run the risk of decreasing the patient's nutritional status.
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Publication:OB GYN News
Date:Apr 1, 2000
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