USE OF TRIPTANS IN PREGNANCY

Triptans (almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, and zolmitriptan) are 5HT1-receptor agonists used in the treatment of acute migraine and cluster headache and the prophylaxis of premenstrual migraine.

The available data do not raise concern of an increased risk of congenital malformation following in utero exposure to triptans. However, evidence for individual triptans apart from sumatriptan is extremely limited or lacking, and specific assessment of malformation risk for these drugs is therefore not currently possible.

There is no robust evidence of increased risk of miscarriage following use of triptans as a group or of sumatriptan specifically. Data also do not raise concerns of low infant birth weight or preterm delivery with gestational use of triptans as a group, although data for these outcomes are more limited and no conclusions can be drawn about specific triptans. Because triptans cause vasoconstriction, there are theoretical concerns about effects on placental perfusion and fetal growth. Isolated case reports have noted IUGR following triptan overuse in pregnancy. A single study has assessed the rate of stillbirth after exposure to sumatriptan or naratriptan and, although these data do not raise concern, they are not sufficient to make a robust evidence-based assessment of the risk of stillbirth following triptan exposure. Studies have not provided robust evidence of altered neurodevelopment in children exposed in utero to triptans.

Where triptan use in pregnancy is clinically indicated, use of sumatriptan in preference to the other triptans, for which there are a lack of data, is advised. Where treatment with a different triptan has been established preconceptually, an individual risk-benefit analysis of continuing therapy needs to be undertaken, and the available data considered and discussed with the patient.

Exposure to triptans at any stage in pregnancy would not usually be regarded as medical grounds for termination of pregnancy or additional fetal monitoring. Use of large quantities of a triptan (such as very frequent or extended use) may be an indication for additional fetal growth monitoring. Other risk factors may also be present in individual cases which may independently increase the risk of adverse pregnancy outcome. Clinicians are reminded of the importance of consideration of such factors when performing case-specific risk assessments.