What are your strategies for preventive migraine therapy in breastfeeding patients?

Transfer to milk depends on how highly a medication is protein-bound. Measurable concentrations occur for drugs <70% bound. >85% bound is not expected to have a measurable concentration in infants. Propranolol, amitriptyline, and Depakote are >90% protein-bound so I consider them first. Botox is not expected to cross over to milk, so I also consider that in appropriate patients. While CGRP monoclonal antibody safety data is lacking, the safety of other monoclonal antibody medications has been re...

For me, the treatment of migraine during nursing is an extension of that during pregnancy. My expectation of headaches during pregnancy is that they improve, certainly after the first trimester. I would expect that improvement to continue during nursing until the recurrence of menstruation. If this does not happen and certainly if they worsen or when there is a new onset headache or the onset of a new type of headache, I will further investigate.

Neurological causes are rare and generally only re...

I treat many lactating patients and refer them frequently to LactiMed or Hale’s for safety data. The choice of treatment will always be made collaboratively with the patient. In lactation, unlike pregnancy, most medications are going to be safe as the percentage of medication in the milk is typically going to be negligible. I consider the dyad in choosing treatments and try to avoid those with antihistaminic properties as they may diminish milk supply.

I always avoid medications with strong sedat...