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How can migraine be managed during pregnancy?

Q: My 29 years old wife is pregnant. She is suffering from migraine for the last 5 years. She normally takes Vasograin during migraine pain. Recently she took - Vasograin: at least 10 tablets last month and Inj. Voveran twice and Inj Stemetil twice 2 months back. The doctor asked her to stop Vasograin and suggested an alternative medicine for migraine during pregnancy. She also suggested a blood and urine test and the result of all those tests were normal. She prescribed Folinext D to be taken for 3 months. I consulted a neurologist for migraine and clearly told him that my wife is pregnant and also showed him the prescription of the gynaecologist. The neurologist suggested the following medicines - Sibelium twice daily, Tryptomer and Rizact – 10 daily. What are the side effects of these medications on the fetus? One of the gynaecologists told me that these medicines should not have been taken during pregnancy. Please advise.

A:Management of migraine during pregnancy is a challenging task and hence benefits of various drugs have to be weighed against side effects. Generally, two different types of drugs are required: prophylactic (preventer) and painkiller during attack. Vasograin, a combination of several agents including ergotamine, must not be taken during pregnancy. Tryptomer (amitriptyline) is sometimes helpful in preventing migraine attacks but is of no use in relieving pain during acute attack. It has to be taken for prolonged periods. There is no data on its use during pregnancy. However, it is known that babies born to mothers who were taking amitrityline have suffered from withdrawal symptoms. Therefore, it is best avoided during pregnancy. Sibelium contains flunarizine, which is also helpful in preventing attacks, but has no role in the treatment of acute attack. It has to be taken over prolonged periods. Animal studies have shown that it does not have any adverse effect during pregnancy when normal human doses are given. Studies in lactating female dogs have shown that flunarizine is excreted in milk. Breast-feeding should therefore be discouraged in women taking flunarizine. Rizact (rizatriptan) is meant to relieve pain during an attack and therefore has to be taken for short duration. It is not known to cause any significant adverse effect in the foetus. However it is excreted in the breast milk. Therefore, if possible, it should be avoided during lactation. In your wife's case one prophylatic drug, flunarizine (sold as Sibelium etc.) should be sufficient. However, it should be discontinued soon after labour when the baby starts taking breast milk. For acute attacks the patient can use rizatriptan (Rizact) 5mg to be swallowed whole with liquid and repeat the dose after two hours if necessary. There should be no concern on other medicines taken in the past for very short durations such as Voveran, Stemetil, Pantocid etc.

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