S2 E5: Pregnancy and Breastfeeding

A National Migraine Centre Heads Up Podcast transcript

Pregnancy and Breastfeeding

Series 2, episode 5

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Speaker 1 [00:00:00] Did you know that women are three times more likely to have migraine than men? Hormones have a lot to answer for. Welcome to the Head’s Up podcast brought to you by the National Migraine Centre. The only UK charity treating migraine and headache.


Dr Katy Munro [00:00:22] Well, welcome back to the Head’s Up podcast. And I’m Dr. Katy Munro and I’m with Dr. Jessica Briscoe.


Dr Jessica Briscoe [00:00:29] Welcome back.


Dr Katy Munro [00:00:29] Today’s episode is going to be about migraine in pregnancy and breastfeeding. So we’re going to talk a little bit about how you plan for pregnancy, what is likely to happen during your pregnancy, and also, of course, very important time of breastfeeding your baby afterwards. So, first of all, what would you advise people to do Jess if they’re planning a pregnancy, do they need to take any special precautions about medications?


Dr Jessica Briscoe [00:00:53] Absolutely. Nicely signposted there, Katy. So, yes, I think it’s really important to know that if you’re on any preventatives for migraine, so particularly topiramate and sodium valproate. These are not suitable for use during pregnancy or breastfeeding. So it’s really important if you’re planning a pregnancy and you’re on a preventative to actually just have a chat with your doctor to see whether your preventative is suitable during this time. And there are actually some other things that I think are a really good idea to think about when you’re planning a pregnancy. So trying to make sure that all of your lifestyle triggers are minimised, really. So things like avoiding skipping meals, taking regular exercise, drinking plenty of fluids and also taking your pre-pregnancy vitamins as well can be helpful.


Dr Katy Munro [00:01:39] Yeah, I think it’s always a good idea to have a little talk to your doctor or read around the preconception advice that’s generally given about healthy diet or cutting out alcohol. The vitamin supplements that might be useful, like folic acid, is a very important one. So all those general things when you’re planning for a baby, but in particular with migraine, we say keep your lifestyle as regulated as possible because we know the brain is irritated by a lot of changes.


Dr Jessica Briscoe [00:02:07] Yeah. And if you want a bit more information on that, we have actually done an episode in the first series about triggers and lifestyle as well.


Dr Katy Munro [00:02:13] So of course you’ll be coming off contraception. Your cycle may go back to one that isn’t regulated by hormones that may cause a bit of change in your migraine frequency. But once somebody actually falls pregnant, then there are a couple of things that can happen to migraine frequency, in fact, if you have migraine without aura about 80% of people find that it gets better.


Dr Jessica Briscoe [00:02:35] Yeah. Which- it’s quite interesting cause a lot of people are told the promise that migraine will get better in pregnancy and that is often the case with migraine without aura. Actually, some people can find that the physiological changes of pregnancy, particularly in that first trimester, can actually sometimes make migraine worse in that period of time.


Dr Katy Munro [00:02:56] Yeah. So aura, if you get migraine with aura that can increase during pregnancy, which is a bit of a downside. And I also have had patients who’ve said, oh, my specialist, whoever it was said to me, oh, the answer to your migraine is to get pregnant, which is a very flippant thing and I find rather patronising. So it’s not necessarily going to improve, but a lot of people do find the migraine gets better.


Dr Jessica Briscoe [00:03:19] Absolutely. So migraine with aura can actually, as you’ve said, worsen during pregnancy. And some women can suffer aura for the first time in pregnancy, which which can be quite alarming. I think a lot of people find their first episode of Aura quite scary.


Dr Katy Munro [00:03:33] Yeah, it’s probably to do with the oestrogen levels, isn’t it? Because Aura is more connected with higher oestrogen levels. I think it’s about 9% of women get their first attack through pregnancy. So there are other reasons for getting headaches when you’re pregnant and it’s really important if you’ve never had headaches before or if your migraine changes very dramatically, get it checked out by a doctor, by your specialist GP, the National Migraine Centre, or by your own local GP, and just make sure that that headache isn’t one that needs further investigation.


Dr Jessica Briscoe [00:04:06] I think it’s really important to note that having migraine is not harmful to the health of your baby as well, because a lot of people do worry about that actually. So, you know, it’s very debilitating as we’ve talked about many times in our podcast. And people always get concerns during pregnancy about what the effects of different conditions might be on the developing baby. And then also, I think we also wanted to highlight the fact that after pregnancy, so when you’ve had the baby, the hormone levels change again. So migraine can return quite quickly, actually, after delivery.


Dr Katy Munro [00:04:40] Yes. Dropping oestrogen levels, as we know, is a potent trigger. We talked about oestrogen and and hormonal migraine a lot with Professor Anne MacGregor in the first episode of this series. So if you want to just check back to that, that’s got a lot of very useful information. But yeah, so oestrogen and the changes in oestrogen are very much involved in triggering migraine in this state.


Dr Jessica Briscoe [00:05:04] So we’ve talked a lot about hormones so far. So as I’ve said, it’s often worse in the first trimester for people who have aura, but actually the oestrogen levels tend to stabilise during the second and third trimester, so people tend to find that it improves at that point. There are actually other reasons for it being worse during that first trimester as well. So some people can feel quite unwell.


Dr Katy Munro [00:05:28] Yeah, of course. Yes. And if they have a lot of vomiting or even as bad as hyperemesis, which is the excessive vomiting that some women get in the first few weeks, it may be very difficult to eat and drink regularly.


Dr Jessica Briscoe [00:05:40] Absolutely. And as we’ve discussed many times, that can be a potent trigger for migraine.


Dr Katy Munro [00:05:45] There are some useful medications that are safe to take for nausea and vomiting in pregnancy, and they can also be useful if you’re taking painkillers for migraine. So it’s worth chatting to your doctor about one of those.


Dr Jessica Briscoe [00:05:57] Yeah. So I mean, worth mentioning about metoclopramide and domperidone, which are used, we use them quite commonly as anti sickness medications. So these are thought to be safe in pregnancy, but often we advise to just avoid it during the first trimester.


Dr Katy Munro [00:06:10] I think we just have to be better safe than sorry, but it’s about risk and benefit, isn’t it? And if somebody is really very debilitated by nausea and can’t function and even sometimes hospitalised, then medication may be very, very helpful.


Dr Jessica Briscoe [00:06:26] We also wanted to talk about how you manage migraine in pregnancy, which is really important. You know, if you’re finding that- because a lot of people do worry in pregnancy about taking medications, there’s a lot of information, you know, people are told not to take anything because of the harm to the baby. But if you’re having severe migraine and it’s debilitating you, what can you take?


Dr Katy Munro [00:06:51] Well, exactly. The trouble is, of course, it’s impossible to do studies on pregnant women. It’s ethically not sound. And so the way that we gather data about whether things are safe or not is what we call registry data, which is where people have inadvertently taken medications, then discovered they’re pregnant, and then they have reported, well, the data has been gathered as to whether or not that had any ill effects. So when we had the triptans first being used for acute treatment of migraine, people were very cautious about it. And I’ve certainly even recently had people saying to me, Oh, I can’t take any triptans, I can’t take my normal triptans now I’m pregnant. And that’s actually found to be false now. The registry gathering data has got information now for many, many years, and there doesn’t seem to be any worry about taking triptans in pregnancy.


Dr Jessica Briscoe [00:07:42] Absolutely. You can also use other painkillers. So things like aspirin and ibuprofen, which people commonly use. Now, you have to be a little bit careful in the third trimester for ibuprofen and also aspirin you’ve got to be a little bit careful about when you take it as well.


Dr Katy Munro [00:08:00] It’s more because if you’re taking it close to the time that the baby is born, then it can have effects on the circulation of the baby and change- there’s a circulatory change that has to happen when the baby’s born to enable its blood supply to function in the way that is normal. So we we would say paracetamol is the painkiller of choice in pregnancy. But of course, a lot of times people don’t find paracetamol terribly strong for migraine pain. So you can take aspirin in the first and second trimester. So that’s the first six months of pregnancy and you can take ibuprofen. But in the final three months, I would say be very careful about it. And then, of course, codeine, our biggest bugbear.


Dr Jessica Briscoe [00:08:46] We love codeine, don’t we, Katy.


Dr Katy Munro [00:08:47] Oh, it’s a no no from us. And we don’t like anybody taking codeine for any kind of migraine pain, whether they’re pregnant or not. So avoid that one.


Dr Jessica Briscoe [00:08:57] And then we’re also talking about I think it’s good to talk about supplements as well because some people do like to use supplements to sort of prevent their migraines. So any that are safe during pregnancy?


Dr Katy Munro [00:09:08] Well I usually encourage people to to take some magnesium because we know that magnesium is also useful in pregnancy and we know that it can help calm down the irritability of the brain. So magnesium seems to be safe. Riboflavin is safe in pregnancy, but I don’t think it’s advised in breastfeeding. So that one is vitamin B2. Both of those are usually advised in a high dose for the non-pregnant migraine patient, but they can be taken in pregnancy. But be more careful with taking vitamin B2 if you’re breastfeeding.


Dr Jessica Briscoe [00:09:45] Absolutely. And, I think I mentioned preventatives at the beginning. And, how you have to think about which ones you can take if you’re already on a preventative. Now, we’ve already said that topiramate and sodium valproate are not safe to be taken during pregnancy.


Dr Katy Munro [00:10:02] Absolutely not.


Dr Jessica Briscoe [00:10:03] Are there any that are safe to be taken in pregnancy?


Dr Katy Munro [00:10:05] So the first line would probably be amitriptyline or propranolol. I think propranolol is probably the first one that we would go to, assuming that people haven’t got asthma or a contraindication to taking that medication. But amitriptyline is a safe alternative. Some people have taken pizotifen, which is something that we used to use more frequently, kind of slightly gone out of fashion. But I have still got some patients who find it useful.


Dr Jessica Briscoe [00:10:34] I’ve seen it creeping back in actually. Yeah.


Dr Katy Munro [00:10:37] So yes, the message is really that you don’t have to stop everything and just suffer. There are ways we can prescribe or give supplements and of course, lifestyle measures are always the key thing that needs to be going on in the background. What about greater occipital nerve blocks?


Dr Jessica Briscoe [00:10:56] Yeah, so I’m actually quite a big fan of these in pregnancy generally. So if you’ve listened to our other podcast episodes you and Dr. Naz spoke about nerve blocks, didn’t you?


Dr Katy Munro [00:11:06] Yes.


Dr Jessica Briscoe [00:11:07] They’re actually- this can be really useful for women who are having sort of quite a lot of attacks during pregnancy, where they don’t particularly want to take a preventative medication or they’re not particularly keen on taking lots of painkillers. So you want to avoid that medication overuse headache. It is safe to take in pregnancy as it’s not absorbed into the general system. It’s not systemically absorbed, so it’s not going to give any harm to the baby. And actually, steroids aren’t necessarily a problem. But we always prefer the occipital nerve blocks because it’s something that’s given peripherally. It’s not going to be absorbed into the bloody system, certainly.


Dr Katy Munro [00:11:47] Yeah. So just to recap from our previous episodes, so the greater occipital nerve block that we use at the National Migraine Centre is a combination of a steroid and a local anaesthetic, as some places just use the local anaesthetic on its own. Both of those seem to be completely safe in pregnancy. And so that’s a very useful intervention because of course if you’re having a lot of headaches and you’re not functioning and you’re pregnant, of course you may also have other children who are running around and need you to be on duty as a mother and carer. So yeah, it is important to try and keep people functioning as fully as possible.


Dr Jessica Briscoe [00:12:24] And we also talked about Botox in a previous podcast and the fact that at present we’re not advising that this should be used in pregnancy.


Dr Katy Munro [00:12:32] Yeah, we’re a bit cautious with Botox. I think it’s just really a lack of information. It may be that this is something that comes into use again as registry data is gathered. But at the moment it’s not something that we do.


Dr Jessica Briscoe [00:12:46] And also, it’s probably worth talking about the monoclonal antibodies, CGRP.


Dr Katy Munro [00:12:50] Yes. Oh, yes, that’s true. So these are the very exciting new medications that people give themself by injection once a month. The advice at the moment is that if you are planning a pregnancy, you must leave about a six month gap between your last injection and trying for pregnancy. So just bear that in mind. Good reminder there, Jess.


Dr Jessica Briscoe [00:13:15] I think a few more points about breastfeeding as well. We’ve talked a lot about pregnancy.


Dr Katy Munro [00:13:19] Yeah. So hopefully breastfeeding is something that every woman will consider. Obviously not everybody can manage it, but it’s by far the best thing for your baby. And there’s increasing evidence, which I’ve been listening to lately on other podcasts about the microbiome. So the gut flora of the baby is really helped. First of all, if they have skin to skin contact with their mum and dad very soon after delivery and also if they’re breastfed. So if you’ve had to sadly have a caesarean section rather than a natural delivery, then it’s very useful to breastfeed your baby, partly because it will help their general immune system. But we know that having a good gut health is important for anybody to try and help them with their migraine as well.


Dr Jessica Briscoe [00:14:04] Absolutely. And then I think triptans in lactation or breastfeeding is an important thing to talk about. Traditionally been quite controversial.


Dr Katy Munro [00:14:14] Yeah. So the trouble is, when you’re having something as a mother in terms of medication, we are always concerned about how much of that will get through to the baby. So this is why we don’t advise aspirin, because there’s a theoretical risk that aspirin could get through to the baby. And there is a very rare condition called Reye’s syndrome in children, which is why we don’t give them aspirin. So that is one that I’d say to people, avoid aspirin if you’re breastfeeding, paracetamol is fine. Ibuprofen. What do you say about that?


Dr Jessica Briscoe [00:14:48] I’d say that’s fine.


Dr Katy Munro [00:14:49] Yeah, I think it’s fine.


Dr Jessica Briscoe [00:14:50] Because you don’t have that risk of Reye’s syndrome with ibuprofen.


Dr Katy Munro [00:14:54] Yes. And then the triptans. Sumatriptan is certainly fine. But some of the triptans are a little bit longer lasting. They hang around in the body a bit longer. So. What’s your advice about those?


Dr Jessica Briscoe [00:15:08] Yeah. I mean, so actually, you know, one of the longest acting ones frovatriptan, it dissolves in fat actually so I tend to advise to avoid that.


Dr Katy Munro [00:15:18] So avoiding that frovatriptan.


Dr Katy Munro [00:15:20] And it’s a long acting one so we don’t know how long it would hang around in the body. So I’m not sure if that would pass along in the breastmilk. There’s, one of Katy’s favourite phrases, pump and dump.


Dr Katy Munro [00:15:31] Oh yeah.


Dr Jessica Briscoe [00:15:32] You hate that don’t you.


Dr Katy Munro [00:15:33] I do hate that. It’s horrible.


Dr Jessica Briscoe [00:15:36] It’s this term that used to be used about using triptans. So historically people were told to leave 12 hours between taking sumatriptan and breastfeeding and they were told to express and throw away the milk, hence the term pump and dump. Generally we don’t recommend that.


Dr Katy Munro [00:15:54] We don’t recommend that now. I think it is quite safe to breastfeed even after sumatriptan but some of the others, they’re still saying be careful maybe have 12 to 24 hours after taking a triptan before you breastfeed again. So I think the other thing we haven’t mentioned is there a very useful website called Bumps, which is the UK safety of medicines in pregnancy websites. If you type in Bumps, B-U-M-P-S, or medicines in pregnancy, you will find that website and you can look up any of the medications you’re thinking of taking and see what the advice says and that has very good current up to date advice.


Dr Jessica Briscoe [00:16:35] Yeah I find that website quite useful actually i have to say.


Dr Katy Munro [00:16:39] So we know that migraine is a genetic condition and we know it runs in families. And there’s been some evidence recently that babies who get infantile colic may go on to have migraine. There’s still a lot of research going into this. So that’s the thing I tend to flag up to new mums or even to somebody planning a pregnancy and say just, you know, think about just keep an eye on your kids. Because if they start to get funny colicky things or travel sickness or maybe tummy aches as they’re growing up, if you’re a migraine sufferer, they might have had that little tendency. And then it’s really a question of thinking about all the lifestyle things that we talk about for them, and that can be very helpful. So again, pointing you to our migraine in children episode for more information. So slightly distracted from our topic, but I think it’s quite useful to remind people.


Dr Jessica Briscoe [00:17:29] I completely agree actually. So I think in summary, the majority of women who have migraine without aura improved during pregnancy, but there are people, particularly if you have aura, that can find that their migraines do get worse and some women can have their first migraine during pregnancy. It’s really important if you’ve had your first attack during pregnancy to actually see a doctor just to make sure that it’s not one of those more worrying types of headache.


Dr Katy Munro [00:17:56] And they’re quite rare, but they’re quite significant and they do need to be checked out. If you’re a typical migraine sufferer and you get your normal migraine, there’s no need to rush off to the doctor. It’s just to follow our guidance, really. And what about future attacks? Jess, do you find that a pregnancy leads to worsening and worsening forever after or what do you think?


Dr Jessica Briscoe [00:18:19] Not necessarily. I mean, often I find that if people are hormonally sensitive, I think is the best way to describe it and find that if they’ve had sort of changes in their migraine pattern during pregnancy, that can sort of indicate that they may have issues with changing hormone levels in the perimenopause, but it’s not really a hard and fast rule I find.


Dr Katy Munro [00:18:38] Of course, the other thing around, just after babies are born and sometimes as much as a year or even longer, sleep disturbance is quite a problem. Certainly one of my children was disturbing my sleep for many years. She doesn’t do it now. She’s in her mid twenties. But sleep disturbance, irregular routine in terms of eating and busy mums having to snatch food when they can, you know, just keep looking after yourself and making sure that you’re caring for your brain because everybody benefits if the mothers are feeling a bit more happy and not impacted by these horrible conditions.


Dr Jessica Briscoe [00:19:18] Absolutely.


Dr Katy Munro [00:19:19] That’s lovely. So we are hopefully going to be talking to a patient who had migraine in pregnancy and we’ll go over to her shortly.


Swati [00:19:30] Thank you for joining us on our podcast, Rita.


Rita [00:19:33] Thank you so much for having me.


Swati [00:19:35] Now, I’m going to start off firstly by congratulating you on your pregnancy. So a big congratulations from team NMC and Heads Up Podcast.


Rita [00:19:44] Thank you so much.


Swati [00:19:45] This episode is about migraines during pregnancy, so I just wanted to sort of get a bit of an idea of how you migraines have been before you got into your pregnancy.


Rita [00:19:55] Yeah so the years prior to pregnancy, they had gone down a lot. I used to have much more frequent and intense migraines when I was younger. But I was getting, you know, maybe once a month some sort of headache, really bad ones, only maybe three times a year. In order to be able to safely get pregnant. I actually was advised by one of your great doctors to get off of a preventative migraine medicine that I had been on for many years. So that was the Topiramate and or Topamax, I’m not sure which one you call it, but that was, you know, probably something that happened before pregnancy, but was a bit of a challenge in terms of my migraines did get more frequent for a while initially after getting off that medication and then they settled down a bit again. But then, after getting pregnant in the first trimester, I started getting migraines like once a week, which was challenging. I know some of your patients and listeners probably get them even more than that so that may not sound like much, but because they had been under control for such a long time, it felt like quite a lot.


Swati [00:21:13] It just felt like something different. So it changed after your pregnancy started.


Rita [00:21:18] So yeah, the first trimester, I think your hormones are just all over the place. It’s a bit of a rollercoaster anyway, and I think that was just kind of part of it. But also, I wasn’t really clear on what I, I mean, besides that you can take paracetamol, I wasn’t really clear on what I could be taking or doing.


Swati [00:21:37] Medication.


Rita [00:21:37] Exactly. So I came back in for a visit at the National Migraine Centre and that was really helpful because the doctor was just able to tell me that there’s also an anti-nausea that I could take and I could couple that with paracetamol that, you know, dissolves to work more rapidly. So I found that that combination really helped. But in my second trimester, I barely got any headaches. I’ll have days where I feel like maybe more a bit foggy, maybe it’s almost like I have the migraine symptoms but without the actual migraine.


Swati [00:22:12] Headache.


Rita [00:22:13] Yeah. So I’ve had a couple of days like that. But yeah, it’s really changed in my second trimester. I suppose my hormones are kind of settling down a little bit.


Swati [00:22:24] Okay. Oh, that’s really interesting. Is there anything else that helps you with your migraines like while you’re pregnant at the moment? Is there anything else alternatively that you’re doing that helps you with your headaches?


Rita [00:22:38] Well, I do a lot of yoga and meditation. I teach yoga, so I’m quite, you know, into alternative things like that. Different breathing techniques to help soothe my nervous system. So there’s a lot that I do with that. I’m also a sleep therapist, so I make sleep and rest pretty big priorities. I make sure I’m getting, you know, I know as women who are pregnant can completely relate. You feel much more tired and your energy levels are different. So making sure that I do take that rest when I need it and I get rest every afternoon, that’s just really helped me overall. There’s certain things that I probably did before I got pregnant that I avoid now, like Marma Point self acupressure, there’s some that you’re not meant to do when you’re pregnant, but there’s one marma specific point in your hand that you probably know that point between your thumb and forefinger, the kind of fleshy bit, that when you squeeze there, it’s quite good for migraine relief and for headache relief. But you’re not meant to do that if you’re pregnant.


Swati [00:23:48] Oh, okay. So if you had to give any suggestions for women who are thinking, I’ve got migraine, but I’m thinking of probably trying to get pregnant or are in their first two trimesters, is there something you would like to suggest to them?


Rita [00:24:06] Yeah. I mean, just, you know, if they’re unsure about what medicine, if that they’re already on medication and they’re not sure what they should or shouldn’t be on or if they’re not sure about what they can take. Like, I would just really recommend going to see you guys because it was so reassuring just to find out, you know, what I could be doing. And, that was really helpful. I mean, other advice I guess I would say, just to try to take care of yourself and get rest and manage your stress and, you know, try to find other ways to make sure you are nurturing yourself because it’s just a time of so much change in the body.


Swati [00:24:46] True. Perfect. Thank you so much. That’s wonderful.


Rita [00:24:49] No. Thank you!


Dr Katy Munro [00:24:54] We are always delighted to hear that you’ve been enjoying our podcasts. We would be even more delighted if you could quickly find the time to click on the Virgin Giving Link and give us a donation. We do this as part of our work for the charity, the National Migraine Centre, but we do need your support to enable us to keep spending the time doing these podcasts. Thank you very much. The details are in the blurb.


[00:25:21] You’ve been listening to the Heads Up podcast. If you want more information or have any comments, email us on info@NationalMigraineCentre.org.uk. Till next time.

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