Pregnancy and medication?

[Noonoo88]

Hi all. I am on a fair bit of medication for my chronic migraines (75mg amitriptyline daily, 50-100mg sumatriptan as and when needed, strong ibuprofen when needed) and am currently 9 weeks pregnant. I found out early, about 3-4 weeks, and straight away midwife sent an urgent referral to neurology due to the medication and the danger it poses to the pregnancy. I've done a lot of research (taken with a pinch of salt as the internet is filled with mixed views) but the general consensus seems to be that sumatriptan is fairly safe to use if it is not frequent. However amitriptyline has been classed as unsafe in pregnancy. There of course have not been official studies done, but research has shown that use of some anti depressants during pregnancy can cause developmental issues to a foetus. I keep asking and asking both midwife and GP what I should be doing but all I keep being told is to wait for neurology. But we are already at five weeks down the line from referral and I've heard nothing. I know the NHS is completely swamped right now so was aware it would not be quick, but I just want to know what to do about my medication before it's too late and has harmed the baby. Has anyone been in this situation before? Did you get weaned off the medication or did you carry on taking it? Any advice would be appreciated as it's really worrying me

I wasn't taking the same meds as you, but I was basically told to come off everything. I stopped my medication for ulcerative colitis, as I was in remission, and everything for migraines. I'm not going to lie - it's been awful. Paracetamol is like attempting to mend an axe wound with a plaster! But if you do have to come off it, you'll get through it. xxx

I've had a similar issue as you, but I was only prescribed 50mg Sumatriptan for my migraines and used to get a few bad migraines a month so I was worried too about how to manage. I'm almost 12 weeks now and I've found that I haven't really had the same level of migraines I used to get so not sure if the hormones have changed my head for now, I also read Sumatriptan was fairly safe online however there were no real studies on it. I avoided taking it and I asked the midwife about it in my booking appointment and she said not to take it and just to take paracetamol. Now with the nausea I've found it difficult to even take any tablets whatsoever so I've been mostly cold turkey and using the cooling stick on my head and sleeping when I feel a headache coming on. As my sickness and nausea are gradually easing I'm finding I'm getting more headaches now though, so I think an ice pack will be my friend! Praying I can still work from home as it's easier to manage this when you are away from the office. Hope your migraines change too with the new levels of hormones and you find you can reduce your medication anyway. I hope you get an answer from neurology soon, would be interested to know the answer on this x

Ibuprofen isn't recommended in pregnancy either.
Hopefully they will advise very soon. I think there should be specialist pharmacists who can help with advising on this kind of thing but it probably varies area to area x

Contact PALS at the hospital. I was struggling to speak to a consultant regarding medication I was on when found out I was pregnant at 5 weeks. I contacted PALS and had a call within 48 hours x

Hi

Congratulations on your pregnancy :)

I'm a chronic migraine sufferer too - normally around 10-15 a month. I was on 30mg Amitryptline and 10mg Rizatriptan (similar to sumatriptan) prior to pregnancy.

In my first pregnancy, I found it hard to get anyone to give me a firm opinion on what to do. So I did my own research (I work in medicine) and decided to try and cut out Amitryptline and switch to sumatriptan, which has been studied more. I couldn't manage on no Amitryptline so went onto 10mg dose and that was okay. At the time, based on retrospective studies of mums who took it there was no evidence Amitryptline causes birth defects - other antidepressants do carry a small risk. Sumatriptan was considered safe anecdotally but no trials had been done. That baby is 6 years old this month and she is completely healthy and thriving in school.

2nd pregnancy (this one - due in 2 weeks) - this time I came off the Amitryptline and Rizatriptan, but I had neurological side effects (muscle spasms/tremors) to a morning sickness medication I was prescribed. I was then prescribed 50mg Amitryptline for those symptoms (not the migraines). GP, Obstetrician, Perinatal Psychiatry and Neurology all said it was safe, and would be safe on higher doses too (100 -150mg was mentioned) if needed. However they are not keen on me taking a triptan this time - presumably because we try to limit the range of medications in pregnancy and the Amitryptline is mostly working (I have 1 migraine a week).

In my first pregnancy it was really frustrating trying to get a straight answer - no one wanted to stick their neck out and advise medication in pregnancy - but this time I'm satisfied that everyone has said Amitryptline is safe in pregnancy if you need it. Obviously it is better to not be on it, but you also need to be well enough yourself to grow a baby and in my case no one knew whether the neuro symptoms I was having might affect baby. The triptans seem to be anecdotally safe if needed, but it's a balance of trying to limit how many meds you are taking.

Like you I would want someone to direct me on what to do - I ended up changing GP in my first pregnancy as they would not help at all. You can always ask your midwife for a obstetric referral for their opinion.

You might also look at the Cefaly device - this is basically a TENS machine for the cranial nerves and blocks migraine signals. I find it really helpful during an attack. It is expensive but I use it daily to reduce attacks too and at least for me it works.

I still have some of the research papers I looked through on migraine and pregnancy - here are some links (and webpages) that might help:

www.medicinesinpregnancy.org/bumps/monographs/USE-OF-TRIPTANS-IN-PREGNANCY/

medicinesinpregnancy.org/Medicine--pregnancy/Amitriptyline/

wchh.onlinelibrary.wiley.com/doi/pdf/10.1002/pnp.137#:~:text=Amitriptyline%20can%20be%20used%20during,sustains%20the%20benefits%20of%20pregnancy.

www.e-lactancia.org/media/papers/Migra%C3%B1aBF2013.pdf

Sitting here with a migraine coming on as we speak. Think I've overused the 4Head stick on my face as my eye is streaming!

I saw a migraine specialist who told me Imigran can be taken if needed, but the OBGYN said it's not recommended as it can constrict the blood vessels. So I never used it. I powered on with paracetamol, which sometimes helped but mostly did nothing. Even then, I've worried I've taken too much of it. But it gets to the stage where I feel I'd rather die than continue with the migraine, so, you know, it's hard not to take it.

The issue with amitriptyline (and even more so with pregabalin that I was on pre pregnancy for my pain) is it causes a shortage of folate which leads to increased foetal mortality and major birth defects. Found I'd have to take 5mg folic acid each day which is about 12/13 times the amount recommended if I was to stay on the pregabalin. You can instead your folic acid intake to help but then you're still stuck with the issue of the ibuprofen and NSAIDs like this are a definite no. Due to my chronic pain I spoke to my GP specially to discuss pain relief and so if I have to I'll take codeine which I usually avoid as opioids make me quite ill.

*increase not instead

PS no official studies done as it's too high a risk but the current guidelines are, it seems, based on a study of limited data from people (I think approx 300) who took pregabalin and other anti epilepsy drugs at the same time (amitriptyline is classed in the same family as pregabalin)

Wow guys thank you so much for your responses! I forgot to check this thread as it had no replies for a while 😁 isn't it crazy how we've all been told/found out different things?! This is all so helpful so I'm very grateful for all your input. I will definitely be looking into that tens machine, it looks very promising. I sympathise with one of the PP that it does feel like you'd rather die than carry on with migraines, it's so bloody hard to know what to do. I know I shouldn't be taking sumatriptan, but honestly I cannot bear the pain. I push it out for as long as I can but there was a point over the last few days where I couldn't even move or open my eyes, it felt like someone was stabbing me through my right eye and even the smallest movement sent me crazy, as the pain would just throb and make me see spots. I had to take it then, I was at my wits end. I considered a&e but soon realised they probably wouldn't be able to do much more than give me a triptan or some other kind of painkiller. I've decided to very slowly reduce the amitriptyline for now. Reducing it by 10mg every 1-2 weeks to see how things go. I figure that's better than going cold turkey and if neurology or whoever else tell me not to I can at least just start taking it again. I will keep you all updated with what happens, so you at least have another example. Congrats on all the your babies as well guys 🥰 thank you again!

Wow

@Countingchicks

PS no official studies done as it's too high a risk but the current guidelines are, it seems, based on a study of limited data from people (I think approx 300) who took pregabalin and other anti epilepsy drugs at the same time (amitriptyline is classed in the same family as pregabalin)

Hi

Just to correct this - amitriptyline is a totally different class of drug to pregabalin. It is not an anticonvulsant, which are dangerous in pregnancy. Amitriptyline is a tricyclic antidepressant, also used at doses for neuropathic pain. Tricyclic antidepressants have not been found to cause birth defects and there's no issue with folic acid. I think you've been looking up the wrong class of drug :)

@L1ttleb1t see I've found some studies where amitriptyline, alongside other tricyclic anti depressants, were thought to cause birth defects... it's so hard to know what to believe! I'm curious what happens to a baby when it's born and the mother has stayed on amitriptyline though (or any drug that requires weaning off it). Does the baby not go through withdrawal?

[quote Noonoo88]@L1ttleb1t see I've found some studies where amitriptyline, alongside other tricyclic anti depressants, were thought to cause birth defects... it's so hard to know what to believe! I'm curious what happens to a baby when it's born and the mother has stayed on amitriptyline though (or any drug that requires weaning off it). Does the baby not go through withdrawal? [/quote]
It is very confusing isn't it? There were some studies questioning limb deformities. I tend to look at review papers rather than individual studies as they will consider whether the research was well designed, whether the results have been replicated etc. Individual studies are more open to bias and mistakes. I brought up these studies with the psychiatrist, who is very pro amitriptyline. He thinks, of course, it's best to make on nothing but if you can't then amitriptyline risks are likely very small. I think your plan sounds very sensible. I also asked about amitriptyline withdrawal - first pregnancy I had to come off amitriptyline in 3rd trimester but psychiatrist said that was the wrong advice and he's never seen neonatal withdrawal from it. I would still come off it if you can - I've been told not to in this pregnancy :( it's all weighing up a lot of unknowns/uncertainties.

This looks like a helpful summary of studies into amitriptyline:

doctorlib.info/pregnancy/drugs-pregnancy-lactation/50.html

Good luck with whatever you choose to do. I don't think there is a wrong or right answer on this one - whatever you do is the best decision you can make now based on the information you have.

It is very confusing isn't it? There were some studies questioning limb deformities. I tend to look at review papers rather than individual studies as they will consider whether the research was well designed, whether the results have been replicated etc. Individual studies are more open to bias and mistakes. I brought up these studies with the psychiatrist, who is very pro amitriptyline. He thinks, of course, it's best to make on nothing but if you can't then amitriptyline risks are likely very small. I think your plan sounds very sensible. I also asked about amitriptyline withdrawal - first pregnancy I had to come off amitriptyline in 3rd trimester but psychiatrist said that was the wrong advice and he's never seen neonatal withdrawal from it. I would still come off it if you can - I've been told not to in this pregnancy :( it's all weighing up a lot of unknowns/uncertainties.

Bless you it's all very hard. I'm surprised there isn't withdrawal for the baby, but happily surprised for sure. My migraines have been less frequent so far in this pregnancy, but when they come they are definitely more severe. I'm happy to come off the medication, as long as they don't worsen again. If they do then I guess I have to look after myself as I'm no good to anyone, least of all the baby, if I can't move or eat or drink from the agony of migraines. How far along are you @L1ttleb1t ?

Slightly different reason, but I paid privately for an appointment with an obstetric neurologist prior to pregnancy, as I was on a LOT of medication. Would it be feasible for you to see one privately? IIRC it was about £300 - the wait to see neurologists on the NHS can be ridiculous.

@Noonoo88 I've got my c section booked for 14th January.... Nearly there!

@ginandtonicformeplease

Slightly different reason, but I paid privately for an appointment with an obstetric neurologist prior to pregnancy, as I was on a LOT of medication. Would it be feasible for you to see one privately? IIRC it was about £300 - the wait to see neurologists on the NHS can be ridiculous.

I could probably find the money if I really had to, did you find it was worth it and beneficial to you?

[quote L1ttleb1t]@Noonoo88 I've got my c section booked for 14th January.... Nearly there![/quote]
Oh my gosh that's so soon! Baby will be a great age when the summer gets here, crawling about in the garden ☺️ congrats 🎉

@Noonoo88 Yes it was worth it: he specialised in neurological conditions and pregnancy, and was able to reduce my meds to a safe level for a baby, although I did have to stay on one that is contraindicated in pregnancy - but the specialist was able to put my mind at ease about that. I see a neurologist privately as the waiting list in my area for the NHS is years not months, and he was the one who recommended an obstetric neurologist as a one-off as a regular neurologist may not have the detailed knowledge about medication and pregnancy.

[quote ginandtonicformeplease]@Noonoo88 Yes it was worth it: he specialised in neurological conditions and pregnancy, and was able to reduce my meds to a safe level for a baby, although I did have to stay on one that is contraindicated in pregnancy - but the specialist was able to put my mind at ease about that. I see a neurologist privately as the waiting list in my area for the NHS is years not months, and he was the one who recommended an obstetric neurologist as a one-off as a regular neurologist may not have the detailed knowledge about medication and pregnancy.[/quote]
Yes that's what I'm fairly concerned about. I can't see the neurologist I've been referred to being able to give me too much pregnancy-related advice but I guess I won't know until I see him. Luckily I'm being kept a close eye on anyway but the midwives, so I'm just hoping that if there is ever a problem they will spot it asap 🤞🏻 thank you for your help

@Noonoo88 did u stay on ur meds ? Xx