Safety and Effectiveness of Pain Medications for Migraine Management During Pregnancy and Lactation

The management of migraine during pregnancy and lactation poses a major challenge owing to the paucity of safety data. While very little safety data are available for new targeted migraine therapies such as calcitonin gene receptor protein (CGRP) blocking medications, including the CGRP monoclonal antibodies and gepants, well-established migraine therapies such as topiramate, valproate, and dihydroergotamine have known risk for teratogenicity. Likewise, the safety evidence for commonly used therapies for migraine in pregnancy such as propranolol and verapamil is of low quality, and the level of evidence for efficacy of verapamil is limited. Meanwhile women experience migraine at the highest rates during their reproductive years necessitating an effective and balanced approach that considers maternal and fetal risk as well as optimal benefit to the patient to ensure adequate and appropriate treatment during pregnancy and lactation. The purpose of this review is to provide an overview of the available data on the safety of available and efficacious medications in the management of migraine during pregnancy and lactation. Based on more recent studies, there is increased evidence for use of more specific and efficacious medications for migraine, such as onabotulinumtoxinA, local nerve blocks with lidocaine, and triptans during pregnancy and lactation.