Do I Really Have To Give Up My Migraine Meds While Pregnant?

My migraine med has been a lifesaver. But I’ve been told I can’t be on it for six months preconception through breastfeeding. Being unmedicated isn’t an option for me, and there aren’t good alternatives or concrete info on harms that I can find. What are my risks?

—Marissa

I am assuming that the medication you’re talking about is topiramate, usually sold as Topamax, which has been a game changer for many people with migraines. As you say, there aren’t a lot of good alternatives to it.

The concern with use in pregnancy is twofold. First, data suggests that use of the drug in the first trimester (which would extend to a period of preconception) increases the risk of oral cleft birth defects. Although this is a relatively rare defect — base rate of about 1 in 1,000 — the risk is estimated to be three times as high with topiramate. The effects seem to be strongly dose-dependent: individuals who are taking this for epilepsy, where the dosage is much higher, have a nine times elevated risk.

Later in pregnancy, there are also elevated risks for low birth weight. Again, these effects are largely estimated off a population with epilepsy, who are taking higher doses. The degree of elevation of risk with the smaller doses typically used for migraines is less clear in the data.

During breastfeeding, use of this drug is generally thought to be safe, although diarrhea is occasionally reported in infants.

Where does this leave you? It’s a hard question. Some women find their migraines improve during pregnancy, so there is perhaps an argument for experimenting with stopping medication. But there may also be a case for identifying the lowest workable dose and continuing on it, knowing that there may be some small risk.

My best advice here is to try to get your OB and your migraine doctor to talk to you together — multiple perspectives at the same time may improve decision-making.