Can propranolol be used safely during pregnancy? If not, what alternative treatment of migraine is

Fråga: Can propranolol be used safely during pregnancy? If not, what alternative treatment of migraine is recommended? The question concerns a 30-year-old woman, now in week 20 of pregnancy, who takes propranolol 30 mg daily as migraine prophylaxis.

Sammanfattning: Maternal propanolol treatment has in rare cases been reported to cause bradycardia and hypoglycemia in the newborn baby. It is therefore suggested that propranolol, as migraine prophylaxis, is stopped during the last trimester of pregnancy, especially as the symptoms decrease in this period in most women anyway. Paracetamol is a safe alternative to treat acute attacks.

Svar: Questions concerning the treatment of migraine during pregnancy has previously been answered in Drugline. The use of propranolol during early pregnancy is not considered to increase the risk for fetal malformations. (A slightly increased incidens of malformations in babys born to mothers treated with beta-blockers, cannot be distinguished from risk caused by hypertension in itself). However, propranolol treatment of the mother has, in a few cases, been reported to cause bradycardia and hypoglycemia in the newborn baby. Therefore, if possible, it is recommended to stop the treatment, or at least minimize the dosage, towards the end of pregnancy (1).

As for alternative non-prophylactic treatment regiments, the use of nonsteroidal antiinflammatory drugs and aspirin is also to be avoided during the last trimester, mainly due to their possible effect on fetal circulation (preterm closure of the ductus arteriosus) (2).

Ergotamins are contraindicated throughout pregnancy, due to their ability to induce uterine contractions (3).

Sumatriptan is one of the most commonly prescribed drugs for the treatment of migraine today. The Swedish Medical Birth Register contains information from 1119 children born to mothers exposed to sumatriptan during the first trimester. No increase in malformations has been detected in this material (4). Neither has any such case reports been found in Medline. It can be concluded that sumatriptan, in moderate doses, can be used safely during early pregnancy. However, information concerning possible side-effects of maternal sumatriptan use during late pregnancy or the perinatal period is still scarce. One retrospective prescription-linkage study (connecting pharmacy prescriptions of sumatriptan to a birth outcome register) indicates an increased risk of preterm delivery compared with migraine controls (women who had sumatriptan prescribed before, but not during pregnancy). The odds ratio was 6.3 with a 95 percent confidence interval of 1.2-32. The authors comment that this finding may reflect eg the impact of disease severity (5).

Paracetamol is considered safe during pregnancy. For treatment of acute migraine attacks, 1000 mg paracetamol, preferably as a suppository, is recommended as a safe choice in late pregnancy.

The occurrence of migraine in women is influenced by hormonal changes throughout the menstral cycle. Luckily, a majority of women suffering from migraine (55-90 percent) experience a relief of symptoms during pregnancy, and more markedly so during the second and third trimester. An even higher percentage of women with menstrual migraine improve during pregnancy (6).