FAQ Episode 55: Migraine therapy during breastfeeding

Frequently Asked Questions about Natural Migraine Relief

Nov 06, 2024

What Medications Are Safe While Breastfeeding?

“Its a pretty fair chance that if you swallowed it, its in your breastmilk.”

There are some 10,000 births per day here in the U.S. Of these infants, 75% of those are initially breastfed. Around 20-25% of women have some form of migraine, this would mean that ~1500 infants a day are born to breastfeeding mothers who could be on some form of migraine related drug therapy. So, its not surprising that this week one of my Natural Migraine Relief readers asked “What migraine treatments are safe to use during breastfeeding?”

I’ll divide this discussion into two groups: 1) prescription drug therapy, including over-the-counter (OTC) meds and 2) non-drug therapy, focusing on nutritional therapy options.

As always, take this advice to your prescribing physician or your pregnancy care provider to review your individualized needs and medical indications. Also note, this information is specific to post-partum breastfeeding, NOT to use of these therapies DURING pregnancy.

Drug therapy for migraine falls into two general categories: preventive and acute headache therapy:

Preventive drug therapy for migraine:

Beta blockers: these drugs, most often propranolol, have been used successfully for both migraine prophylaxis and also to help with breast pain during lactation. Because of the low levels of propranolol in breastmilk, amounts ingested by the infant are small and have not been found to cause any adverse effects in breastfed infants.
Antidepressants
Amitriptyline is a tricyclic antidepressant that can help prevent migraines. Multiple studies have demonstrated safety for breastfed infants in maternal doses up to 150 mg/day.
Anti-seizure drugs The most commonly used of these drugs is topiramate, or Topamax, which can help prevent migraines by reducing electrical activity in the brain. Maternal doses of topiramate up to 200 mg daily produce relatively low levels in infant serum. Sedation and diarrhea have been reported occasionally in breastfed infants, but most infants tolerate the drug in breast milk well.
Botox injections
Injections of onabotulinumtoxinA (Botox) every 12 weeks can help prevent migraines in some adults. It is thought to not enter breast milk, but many physicians recommend that their patients not take additional Botox until done with breastfeeding. An alternate view is that if the highest botox injection concentration and a concommitant dose of 150 mL/kg daily breast milk intake are used, a breastfed infant would receive a maximum of 5 ng/kg of botulinum toxin A orally per day, which is far below the dose of 12 to 25 units/kg given by injection to children with spastic cerebral palsy. 1 Consult your botox provider for additional details specific to your care.
CGRP monoclonal antibodies or blockers Some antibody based CGRP therapies like Aimovig and Ajovy are large IgG2 monoclonal antibodies which do not readily enter breastmilk. Even if ingested, it would most likely be destroyed by the baby’s gastrointestinal tract.
Emgality, on the other hand, is an IgG4 antibody, which is believed to enter milk more significantly, and should probably not be frontline therapy for breastfeeding women. Some studies find that the rise in prolactin during breasfeeding can sensitize nerves to migraine pain may be mediated by an increase of CGRP, making this therapy option useful for some lactating patients.2
If you are using a CGRP med, you may want to review FAQ Episode 26: Your response to the latest migraine drugs vs the root causes of your headaches and also FAQ Episode 54: Dr. Baker interviewed on Migraine management looking for my comments on the use of the nutrient CoQ10 to augment CGRP response, located at the end of Question 9 in that post.

Acute drug therapy for migraine headache:

Acetaminophen: can be safely used for migraine pain within dosing guidelines.

NSAIDs: non-steroidal pain relievers like ibuprofen or naproxen can be use short term without associated harm for breastfed infants.

Opiate pain relievers: should be routinely avoided if possible as it passes readily into breastmilk.

Triptan drugs: The manufacturers suggest withholding breast feeding for 12 hours after taking a triptan drug like sumatriptan. The amount in breastmilk is very low, but if you only use triptan therapy two to three times a month, you may want to pre pump enough extra breast milk to have some on hand to cover these episodes.

Anti-emetics: drugs for migraine associated nausea. The most commonly used is odansetron, or Zofran, which is safe for use during breastfeeding.

For more information on specific drug therapy during lactation, see the Drugs and Lactation Database (LactMed) from the Bethesda National Institute of Child Health and Human Development which has a searchable database on the safety of specific drug therapy during lactation.

Preventive nutritional therapy options used for migraine:

In my Natural Migraine Relief course’s Migraine Action Plan I list 32 different non-drug nutritionals out of more than 90 specific potential interventions to reduce the root causes of migraine. These include:

Vitamins and Minerals: Vitamins D3, K-2, A, C, CoQ10, riboflavin, thiamine, zinc, niacin, methylated forms of B6, folate and B12, magnesium citrate and threonate, iodine. Some notable points of interest here:

Vitamin C 500mg a day is not only safe but when combined with 100 units of vitamin E, it also improves the milk’s biochemical antioxidant profile.
high dose riboflavin (B2) generally has a wide safety margin and high-dose IV riboflavin has been safely used as an adjunct in the management of hyperbilirubinemia in infants. As a lactating mother may need up to 50% more riboflavin daily, the usual 200-400 mg riboflavin per day used for migraine prophylaxis can be a reasonable dose, especially if the mother’s has worsened headaches when off of riboflavin.
if using Vitamin A, it is advised to use no more than 3000mcg of vitamin A daily when breastfeeding.
iodine intake should be in the 250 microgram/ml level and is advised to stay less than 500 mcg/ml at max while breastfeeding.

Food based herbs, amino acids or nutritionals: curcumin, quercitin, butterbur, CBD, kava, tryptophan, SAMe, 5-HTP, adrenal adaptogens, omega-3 fatty acids, probiotics, histamine blocking enzymes and pine bark extract.

Non-drug hormone support: melatonin, DHEA, pregnenolone, and progesterone. One could also include here rx requiring estrogen and testosterone as therapy, but since they require a doctor’s prescription and supervision, I’ll not comment here on their use during lactation.

Of the above listed non-prescription interventions, here are four that deserve further attention to their use during breastfeeding:

Butterbur has ingredients known as pyrrolizidine alkaloids (PAs) that could cause liver inflammation in infants and small children. This risk is minimized if not eliminated if you use PA free extracts, such as the brand name Petolodex. They are more expensive, but if the anti-inflammatory benefit from butterbur works for you, this would be the better form to use, whether breastfeeding or not.
Kava: no specific studies, but generally advised to be minimized with breastfeeding in what academics cheerfully term “an abundance of caution.”
DHEA: should consider monitoring for both DHEA and testosterone levels if taken during lactation, especially if using more than 10 mg/day.
CBD: it is advised NOT to use any CBD or THC containing products while breastfeeding.

Safety of Drug vs Non-drug migraine therapy options

In the above mentioned circumstance we are balancing migraine prevention for mom with safety for your breastfeeding infant. Fortunately there is a wide margin of safety for most prescription and non-drug therapy options. I’d like to finish this post with an important therapy option to consider as one transitions from third trimester through labor and delivery on to breastfeeding your child.

Progesterone and Migraines: from pregnancy into the post-partum months

For many women, migraines improve through the pregnancy, but often then recur and rebound in the weeks to months after delivery. For many women whose migraines have had a hormonal and cyclic component, this can be due to the surge of progesterone through mid to late pregnancy, and its abrupt drop right after. I’ve had many patients tell me that their mid pregnancy months were “the most headache free I’ve been in my adult life.” Almost without exception these individuals have likely been running inadequate progesterone levels dating even back to their menarche (onset of periods.) If you are one of these individuals, you may benefit from post-partum progesterone support to avoid or minimize migraine or post partum depression. It is entirely safe with breastfeeding. If your physician can assist with this, you can take either micronized capsules in the 50-200 mg/day range, or topical cream, often in the 50-150 mg/day dosage range. If you do not have access to a hormone knowledgeble prescriber, you can safely use a trial of OTC bought 20-40 mg/dose range, applied to the skin as 2-3 doses per day, and rotating among your forearms or inner thigh in areas of application.

If you would like to see the entire range of potential applied natural therapy options mentioned above, you can join us as a paid subscriber. Find more information on the Natural Migraine Relief for Women course at: FAQ Episode 42: What can I learn from the Natural Migraine Relief course? and The Natural Migraine Relief for Women course: Table of Contents

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