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Westberg SM, Arellano R, Cieri-Hutcherson NE, Heinrich NT, Herman AM, Lodise NM, McBane S, Ofili TU, O'Grady N, Sankey KH. Pharmacotherapy of Chronic Neuropsychiatric Conditions During Pregnancy. Nurs Womens Health 2024; 28:227-241. [PMID: 38702041 DOI: 10.1016/j.nwh.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 12/08/2023] [Accepted: 03/28/2024] [Indexed: 05/06/2024]
Abstract
Many pregnant persons will experience neuropsychiatric conditions during pregnancy, including migraine, attention deficit disorder, depression, and anxiety. Treatment of each of these conditions requires shared decision-making among the individual, family, and health care team. Although medications may include risk, the benefits often outweigh the potential fetal risks. In this article, we review pharmacologic treatment options for each of these conditions and appropriate use in pregnancy to maintain the stability of conditions and to optimize maternal and fetal outcomes.
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Phillips K, Nirantharakumar K, Wakerley BR, Crowe FL. Trends in the prevalence and pharmacological management of migraine during pregnancy in the UK, 2000-2018. J Neurol Neurosurg Psychiatry 2024:jnnp-2024-333530. [PMID: 38569874 DOI: 10.1136/jnnp-2024-333530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 03/19/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND Migraine is common in women of reproductive age. This study aimed to (1) describe the prevalence of migraine in pregnant women in the UK, (2) identify drugs commonly prescribed for migraine during pregnancy and (3) identify characteristics associated with being prescribed medication for migraine during pregnancy. METHODS The Clinical Practice Research Datalink pregnancy register, a database of pregnancy episodes identified in anonymised primary care health records, was used.Crude and age-standardised prevalence of migraine during pregnancy and the proportion of women with migraine prescribed drugs used for migraine management were calculated for each year between 2000 and 2018.Logistic regression was used to describe the relationship between patient characteristics and being prescribed migraine medication during pregnancy. RESULTS 1 377 053 pregnancies were included, of which 187 328 were in women with a history of migraine. The age-adjusted prevalence increased from 11.4% in 2000 to 17.2% in 2018. There was an increase in the rates of prescription for numerous medications for the management of migraine.Older women (adjusted OR (aOR) 1.41 (1.20 to 1.66)), women of black (aOR 1.40 (1.32 to 1.48)) and South Asian ethnicity (aOR 1.48 (1.38 to 1.59)), those living in the most deprived areas (aOR 1.60 (1.54 to 1.66)), women who were obese (aOR 1.39 (1.35 to 1.43)), smokers (aOR 1.15 (1.12 to 1.18)) and those with comorbid conditions were more likely to receive a prescription during pregnancy. CONCLUSIONS Rates of recorded migraine have increased over the past two decades as well as rates of prescribing in women with migraine. Higher prescribing rates are seen in certain groups, which has the potential to exacerbate health inequalities.
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Affiliation(s)
- Katherine Phillips
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Krishnarajah Nirantharakumar
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Midlands Health Data Research UK, University of Birmingham, Birmingham, UK
| | - Benjamin R Wakerley
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Francesca L Crowe
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
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Louchet M, Tisseyre M, Kaguelidou F, Treluyer JM, Préta LH, Chouchana L. Drug-induced fetal and offspring disorders, beyond birth defects. Therapie 2024; 79:205-219. [PMID: 38008599 DOI: 10.1016/j.therap.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 11/09/2023] [Indexed: 11/28/2023]
Abstract
Studies on drug utilization in western countries disclosed that about nine over ten women use at least one or more drugs during pregnancy. Determining whether a drug is safe or not in pregnant women is a challenge of all times. As a developing organism, the fetus is particularly vulnerable to effects of drugs used by the mother. Historically, research has predominantly focused on birth defects, which represent the most studied adverse pregnancy outcomes. However, drugs can also alter the ongoing process of pregnancy and impede the general growth of the fetus. Finally, adverse drug reactions can theoretically damage all developing systems, organs or tissues, such as the central nervous system or the immune system. This extensive review focuses on different aspects of drug-induced damages affecting the fetus or the newborn/infant, beyond birth defects, which are not addressed here.
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Affiliation(s)
- Margaux Louchet
- URP 7323 "Pharmacologie et évaluation des thérapeutiques chez l'enfant et la femme enceinte", Université Paris Cité, 75000 Paris, France; Service de gynécologie-obstétrique, Fédération hospitalo-universitaire PREMA, hôpital Louis-Mourier, AP-HP Nord - Université Paris Cité, 75000 Paris, France
| | - Mylène Tisseyre
- URP 7323 "Pharmacologie et évaluation des thérapeutiques chez l'enfant et la femme enceinte", Université Paris Cité, 75000 Paris, France; Centre régional de pharmacovigilance, service de pharmacologie périnatale, pédiatrique et adulte, hôpitaux Cochin-Necker, AP-HP Centre - Université Paris Cité, 75000 Paris, France
| | - Florentia Kaguelidou
- URP 7323 "Pharmacologie et évaluation des thérapeutiques chez l'enfant et la femme enceinte", Université Paris Cité, 75000 Paris, France; Centre d'investigation clinique pédiatrique, Inserm CIC 1426, hôpital Robert-Debré, AP-HP Nord - Université Paris Cité, 75000 Paris, France
| | - Jean-Marc Treluyer
- URP 7323 "Pharmacologie et évaluation des thérapeutiques chez l'enfant et la femme enceinte", Université Paris Cité, 75000 Paris, France; Centre régional de pharmacovigilance, service de pharmacologie périnatale, pédiatrique et adulte, hôpitaux Cochin-Necker, AP-HP Centre - Université Paris Cité, 75000 Paris, France
| | - Laure-Hélène Préta
- URP 7323 "Pharmacologie et évaluation des thérapeutiques chez l'enfant et la femme enceinte", Université Paris Cité, 75000 Paris, France
| | - Laurent Chouchana
- URP 7323 "Pharmacologie et évaluation des thérapeutiques chez l'enfant et la femme enceinte", Université Paris Cité, 75000 Paris, France; Centre régional de pharmacovigilance, service de pharmacologie périnatale, pédiatrique et adulte, hôpitaux Cochin-Necker, AP-HP Centre - Université Paris Cité, 75000 Paris, France.
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Phillips K, Clerkin-Oliver C, Nirantharakumar K, Crowe FL, Wakerley BR. How migraine and its associated treatment impact on pregnancy outcomes: Umbrella review with updated systematic review and meta-analysis. Cephalalgia 2024; 44:3331024241229410. [PMID: 38317644 DOI: 10.1177/03331024241229410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
BACKGROUND Migraine is common in reproductive aged women. Understanding the impact of migraine and associated treatments on pregnancy outcomes remains very important. An umbrella review of systematic reviews, with or without meta-analyses, examined the link between migraine and pregnancy outcomes. METHODS We systematically searched Medline, Embase and Cochrane to 27 October 2022. Quality appraisal was carried out using the AMSTAR2 tool. An established framework was used to determine whether included reviews were eligible for update. RESULTS Four studies met review criteria. Migraine was reported to be associated with increased odds ratio (OR) of pre-eclampsia, low birth weight and peripartum mental illness (pooled OR = 3.54 (2.24-5.59)). Triptan-exposed women had increased odds of miscarriage compared to women without migraine (pooled OR = 3.54 (2.24-5.59)). In updated meta-analyses, migraine was associated with an increased odds of pre-eclampsia and preterm birth (pooled OR = 2.05 (1.47-2.84) and 1.26 (1.21-1.32) respectively). CONCLUSIONS Migraine is associated with increased odds of pre-eclampsia, peripartum mental illness and preterm birth. Further investigation of the relationship between migraine and placental abruption, low birth weight and small for gestational age is warranted, as well as the relationship between migraine, triptans and miscarriage risk.Systematic Review Registration: Prospero CRD42022357630.
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Affiliation(s)
- Katherine Phillips
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | - Krishnarajah Nirantharakumar
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Midlands Health Data Research UK, University of Birmingham, Birmingham, UK
| | - Francesca L Crowe
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Benjamin R Wakerley
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- University Hospital Birmingham, Birmingham, UK
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Noseda R, Bedussi F, Gobbi C, Ceschi A, Zecca C. Calcitonin gene-related peptide antagonists in pregnancy: a disproportionality analysis in VigiBase ®. J Headache Pain 2024; 25:10. [PMID: 38243189 PMCID: PMC10799383 DOI: 10.1186/s10194-024-01715-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 01/11/2024] [Indexed: 01/21/2024] Open
Abstract
BACKGROUND Current evidence on the safety of calcitonin gene-related peptide antagonists (CGRP-A) in pregnancy for the treatment of both episodic and chronic migraine is scarce and does not yet provide definitive information. By querying VigiBase®, the World Health Organization global pharmacovigilance database, this study aimed to detect differences in the reporting frequency between CGRP-A and triptans in relation to pregnancy. METHODS Disproportionality analyses on de-duplicated safety reports collected in VigiBase® as of 31.05.2023 reporting exposure to CGRP-A in pregnancy with or without pregnancy outcomes. A Reporting Odds Ratio (ROR) with a 95% confidence interval (CI) was used as a measure of disproportionality and the threshold for the detection of a signal of disproportionate reporting was set with a 95% CI lower limit > 1. FINDINGS Four hundred sixty-seven safety reports reported exposure to CGRP-A in pregnancy, mostly originating from the United States of America (360/467, 77%), more frequently reported by patients (225/467, 48%), who were mainly females (431/467, 92%), and more frequently reported exposure to CGRP-A during pregnancy (400/467, 86%). Compared to triptans, no signals of disproportionate reporting were detected with CGRP-A either for the overall reporting of pregnancy-related safety reports (ROR 0.91, 95% CI 0.78-1.06), for the reporting of pregnancy outcomes (maternal and/or foetal/neonatal, ROR 0.54, 95% CI 0.45-0.66), or for the reporting of foetal/neonatal outcomes (ROR 0.53, 95% CI 0.41-0.68). CONCLUSIONS This study showed that, to date, there are no signals of increased reporting with CGRP-A compared to triptans in relation to pregnancy in VigiBase®. Future pharmacovigilance studies are needed to confirm these findings.
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Affiliation(s)
- Roberta Noseda
- Division of Clinical Pharmacology and Toxicology, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Francesca Bedussi
- Division of Clinical Pharmacology and Toxicology, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Claudio Gobbi
- Department of Neurology, Neurocenter of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
- Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Alessandro Ceschi
- Division of Clinical Pharmacology and Toxicology, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
- Clinical Trial Unit, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Department of Clinical Pharmacology and Toxicology, University Hospital Zurich, Zurich, Switzerland
| | - Chiara Zecca
- Department of Neurology, Neurocenter of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland.
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland.
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Mitrogiannis I, Evangelou E, Efthymiou A, Kanavos T, Birbas E, Makrydimas G, Papatheodorou S. Risk factors for preterm birth: an umbrella review of meta-analyses of observational studies. BMC Med 2023; 21:494. [PMID: 38093369 PMCID: PMC10720103 DOI: 10.1186/s12916-023-03171-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 11/09/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND Preterm birth defined as delivery before 37 gestational weeks is a leading cause of neonatal and infant morbidity and mortality. The aim of this study is to summarize the evidence from meta-analyses of observational studies on risk factors associated with PTB, evaluate whether there are indications of biases in this literature, and identify which of the previously reported associations are supported by robust evidence. METHODS We searched PubMed and Scopus until February 2021, in order to identify meta-analyses examining associations between risk factors and PTB. For each meta-analysis, we estimated the summary effect size, the 95% confidence interval, the 95% prediction interval, the between-study heterogeneity, evidence of small-study effects, and evidence of excess-significance bias. Evidence was graded as robust, highly suggestive, suggestive, and weak. RESULTS Eighty-five eligible meta-analyses were identified, which included 1480 primary studies providing data on 166 associations, covering a wide range of comorbid diseases, obstetric and medical history, drugs, exposure to environmental agents, infections, and vaccines. Ninety-nine (59.3%) associations were significant at P < 0.05, while 41 (24.7%) were significant at P < 10-6. Ninety-one (54.8%) associations had large or very large heterogeneity. Evidence for small-study effects and excess significance bias was found in 37 (22.3%) and 12 (7.2%) associations, respectively. We evaluated all associations according to prespecified criteria. Seven risk factors provided robust evidence: amphetamine exposure, isolated single umbilical artery, maternal personality disorder, sleep-disordered breathing (SDB), prior induced termination of pregnancy with vacuum aspiration (I-TOP with VA), low gestational weight gain (GWG), and interpregnancy interval (IPI) following miscarriage < 6 months. CONCLUSIONS The results from the synthesis of observational studies suggest that seven risk factors for PTB are supported by robust evidence. Routine screening for sleep quality and mental health is currently lacking from prenatal visits and should be introduced. This assessment can promote the development and training of prediction models using robust risk factors that could improve risk stratification and guide cost-effective preventive strategies. TRIAL REGISTRATION PROSPERO 2021 CRD42021227296.
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Affiliation(s)
- Ioannis Mitrogiannis
- Department of Obstetrics & Gynecology, General Hospital of Arta, 47100, Arta, Greece
| | - Evangelos Evangelou
- Department of Epidemiology and Biostatistics, Imperial College London, London, SW7 2AZ, UK
- Department of Hygiene and Epidemiology, University of Ioannina Medical School, 45110, Ioannina, Greece
| | - Athina Efthymiou
- Harris Birthright Research Centre for Fetal Medicine, King's College London, London, SE5 8BB, UK
- Department of Women and Children Health, NHS Foundation Trust, Guy's and St Thomas, London, SE1 7EH, UK
| | | | | | - George Makrydimas
- Department of Obstetrics & Gynecology, University Hospital of Ioannina, 45110, Ioannina, Greece
| | - Stefania Papatheodorou
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, 02115, USA.
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Liu C, Pace S, Bromley R, Dobson R. Exposure to medication for neurological disease in pregnancy - time to consider the long-term implications? EClinicalMedicine 2023; 63:102157. [PMID: 37662523 PMCID: PMC10474373 DOI: 10.1016/j.eclinm.2023.102157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 07/25/2023] [Accepted: 07/26/2023] [Indexed: 09/05/2023] Open
Abstract
A range of long-term neurological conditions may be diagnosed in young adulthood. These conditions are generally not curable, and most people need to take ongoing treatment for symptom control and/or disease modification. When chronic diseases are diagnosed before people have completed their families, there is a need to balance the potential benefits of treatment for the mother against potential risk(s) to the fetus from exposure to medications during pregnancy. Whilst available data regarding short-term fetal outcomes following treatment exposures during pregnancy is rapidly increasing, information regarding longer-term outcomes is more limited. The association of fetal exposure to valproate with serious long-term neurodevelopmental outcomes has highlighted the importance of capturing and evaluating long-term data. In this review we examine available evidence around the long-term effects of treatments used for the most common long-term neurological conditions diagnosed in early adulthood, namely epilepsy, migraine and neuroinflammatory disorders. We draw from existing literature across a range of diseases and discuss strategies to improve future knowledge.
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Affiliation(s)
- Chen Liu
- Preventive Neurology Unit, Wolfson Institute of Population Health, QMUL, UK
| | - Samuel Pace
- Department of Neurology, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Rebecca Bromley
- Division of Neuroscience, School of Biological Sciences, Faculty of Medicine, Biology and Health, University of Manchester, UK
- Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, UK
| | - Ruth Dobson
- Preventive Neurology Unit, Wolfson Institute of Population Health, QMUL, UK
- Department of Neurology, Royal London Hospital, Barts Health NHS Trust, London, UK
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Turankar T, Sorte A, Wanjari MB, Chakole S, Sawale S. Relation and Treatment Approach of Migraine in Pregnancy and Breastfeeding. Cureus 2023; 15:e36828. [PMID: 37123778 PMCID: PMC10147488 DOI: 10.7759/cureus.36828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 03/28/2023] [Indexed: 03/30/2023] Open
Abstract
Headaches are one of the most frequent reasons people visit the neurology department. In 2019, headache issues ranked as the 14th most common cause of disability-adjusted life years globally. According to the International Headache Society, migraine is a particular type of headache that is unilateral, frequently throbbing, associated with vertigo, and sensitive to light, sound, and head movement. A migraine has four stages: premonitory, aura, headache, and postdrome. Migraine is the type of discomfort that most frequently complicates the pregnancy. A migraine is more common in women than in men. Migraines are influenced by increased levels of estrogen during pregnancy and a sharp decrease in those levels during puerperium. Untreated migraine can result in premature labor, hypertension, and low birth weight babies. Menstrual-related events occurred more frequently in migraine sufferers than in non-migraine sufferers. We have explained the relation of sex hormones that trigger migraine. We have also reviewed the therapeutic approach, such as pharmacological and non-pharmacological approaches, for migraine in pregnancy and breastfeeding. A migraine episode during menstruation was slightly more severe and complicated than a headache that wasn't a migraine. Breastfeeding is not prohibited by migraines. The steady estrogen levels brought on by lactating women's lack of menstruation may function as a protective factor. In addition to any required drug therapy, nonpharmacological techniques should always be used as the first line of treatment. Preconception counseling is an essential part of providing headache patients with safe therapy during pregnancy. Supplemental estrogen should not be used by any women who have an aura or who are 35 years of age or older because there is inadequate proof to support any long-term adverse effects. Paracetamol is advised for use in acute therapy during pregnancy. Mothers who used acetaminophen during pregnancy are more likely to have children with hyperkinetic disorders and characteristics resembling attention-deficit/hyperactivity disorder. Menstrual migraine can be treated in a variety of ways, including acute therapy, non-pharmacological therapy, and preconception counseling. Similar tactics are used to treat migraines during pregnancy, but it's important to take the medications' safety rating into account. Migraines and menstrual problems go together. A safeguarding element is a constant estrogen level during pregnancy and breastfeeding. The preferred method of treatment for migraine is non-pharmacological therapy, followed by prenatal counseling. Sumatriptan and acetaminophen are both effective treatments for transient migraine attacks that occur during pregnancy or breastfeeding.
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Mitrogiannis I, Evangelou E, Efthymiou A, Kanavos T, Birbas E, Makrydimas G, Papatheodorou S. Risk factors for preterm labor: An Umbrella Review of meta-analyses of observational studies. RESEARCH SQUARE 2023:rs.3.rs-2639005. [PMID: 36993288 PMCID: PMC10055511 DOI: 10.21203/rs.3.rs-2639005/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
Preterm birth defined as delivery before 37 gestational weeks, is a leading cause of neonatal and infant morbidity and mortality. Understanding its multifactorial nature may improve prediction, prevention and the clinical management. We performed an umbrella review to summarize the evidence from meta-analyses of observational studies on risks factors associated with PTB, evaluate whether there are indications of biases in this literature and identify which of the previously reported associations are supported by robust evidence. We included 1511 primary studies providing data on 170 associations, covering a wide range of comorbid diseases, obstetric and medical history, drugs, exposure to environmental agents, infections and vaccines. Only seven risk factors provided robust evidence. The results from synthesis of observational studies suggests that sleep quality and mental health, risk factors with robust evidence should be routinely screened in clinical practice, should be tested in large randomized trial. Identification of risk factors with robust evidence will promote the development and training of prediction models that could improve public health, in a way that offers new perspectives in health professionals.
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Spiteri JA, Camilleri G, Piccinni C, Sultana J. Safety of drugs used for the treatment of migraine during pregnancy: a narrative review. Expert Rev Clin Pharmacol 2023; 16:207-217. [PMID: 36803196 DOI: 10.1080/17512433.2023.2181157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
INTRODUCTION Migraine is common in females of childbearing age and negatively impacts quality of life. The majority of those with migraine who become pregnant see an improvement in their condition but not all do. Providing evidence-based recommendations for the pharmacological management of migraine in pregnancy is challenging. AREAS COVERED This narrative review provides an update on the safety of drugs used for migraine in pregnancy. National and international guidelines on the management of episodic migraine in adults were used to select the drugs of relevance to pregnant women. The final list of drugs was chosen by a pain specialist who categorized them according to drug class and use in acute management or prevention. PubMed was searched from inception to 31st July 2022 for evidence on drug safety. EXPERT OPINION Obtaining high-quality drug safety data in pregnant migraineurs is difficult not least because exposing a fetus to research-related risks is often considered unethical. There is reliance on observational studies which often group drugs together and lack specificities pertinent to drug prescribing like timing, dosing and duration. Improved statistical tools, study designs and the creation of international collaborative frameworks are ways to advance knowledge on drug safety in pregnancy.
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Affiliation(s)
- Jessica A Spiteri
- Department of Anaesthesia, Intensive Care and Pain Medicine, Mater Dei Hospital, Triq Dun Karm, Malta
| | - Gabrielle Camilleri
- Department of Clinical Pharmacology and Therapeutics, University of Malta, Msida MSD, Malta
| | - Carlo Piccinni
- Fondazione Ricerca e Salute (ReS)-Research and Health Foundation, Casalecchio di Reno, Italy
| | - Janet Sultana
- Exeter College of Medicine and Health, University of Exeter, Exeter, UK
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Barus J, Sudharta H, Adriani D. Study of the Mechanisms and Therapeutic Approaches of Migraine in Women and Pregnancy: A Literature Review. Cureus 2023; 15:e35284. [PMID: 36968932 PMCID: PMC10036867 DOI: 10.7759/cureus.35284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2023] [Indexed: 02/25/2023] Open
Abstract
Headache is a significant and debilitating health problem, affecting more than half of the population worldwide. Migraine is a type of headache that is strongly associated with women and accounts for the high number of years lived with disability among women. The pathophysiology of migraine attacks may begin with a premonitory phase, followed by an aura phase and migraine headache. In women, many factors influence the prevalence of migraine, and sex hormone fluctuations around the menstruation cycle were believed to impact the pathogenesis of migraine. The International Classification of Headache Disorders, 3rd edition identifies menstrual migraine as pure menstrual migraine without aura and menstrually related migraine without aura. While migraine without aura (MwoA) was clearly associated with menstruation, migraine with aura (MwA) was generally unrelated to menstruation. Studies suggested that estrogen withdrawal is a trigger for MwoA, but high estrogen states are a trigger for MwA. During pregnancy, the increase in estrogen hypothetically prevents migraine attacks. There are several strategies for managing menstrual migraine, from acute/abortive, mini-preventive, and continuous preventive treatment. Managing migraine during pregnancy follows a similar strategy, but the drugs' safety profile should be considered.
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Verhaak A, Bakaysa S, Johnson A, Veronesi M, Williamson A, Grosberg B. Migraine treatment in pregnancy: A survey of comfort and treatment practices of women's healthcare providers. Headache 2023; 63:211-221. [PMID: 36695287 DOI: 10.1111/head.14436] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 09/16/2022] [Accepted: 09/22/2022] [Indexed: 01/26/2023]
Abstract
OBJECTIVE The objective of this study was to assess women's healthcare providers' treatment practices for pregnant women with migraine. BACKGROUND Migraine is associated with several maternal and fetal complications during pregnancy, including preeclampsia and preterm birth. Migraine treatment during pregnancy can present significant challenges due to lack of controlled clinical trials and risks associated with specific medications. METHODS Women's healthcare providers were queried regarding practice patterns and comfort with use of acute and preventive migraine treatments during pregnancy. The survey was distributed online. RESULTS The survey was completed by 92 women's healthcare providers (response rate 22.9% [92/402]), with most specializing in general obstetrics and gynecology (91% [83/92]). Approximately one-fourth (26% [24/92]) of respondents indicated they counseled women on migraine treatment in pregnancy as early as before pregnancy contemplation, while over one-third (35% [32/92]) counseled on migraine treatment once the patient became pregnant. The majority of respondents reported feeling somewhat or very comfortable with recommending (63% [58/92]) or continuing (64% [59/92]) acute treatments for pregnant patients with migraine, with highest comfort levels for acetaminophen (100% [92/92] for prescribing or continuing) and caffeine (94% [85/90] prescribing, 91% [82/90] continuing). Higher levels of discomfort were reported with triptans (88% [80/91] rarely or never prescribe during pregnancy). Survey respondents felt less comfortable with recommending preventive migraine treatments to pregnant patients (40% [37/92] somewhat or very comfortable), compared with a higher comfort level with continuing preventive medications (63% [58/92] somewhat or very comfortable). Highest comfort levels were reported with use of magnesium (69% [63/91] comfortable prescribing, 82% [75/92] comfortable continuing) and non-pharmacologic approaches (70% [62/89] comfortable prescribing, 84% [75/89] comfortable continuing). Nearly 40% (35/92) of respondents reported that they typically refer to neurologists or headache specialists for migraine treatment during pregnancy. CONCLUSION This survey of women's healthcare providers revealed varying levels of comfort regarding migraine management during pregnancy, and highlights the need for additional education regarding migraine treatment safety data during pregnancy.
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Affiliation(s)
- Allison Verhaak
- Hartford Healthcare Headache Center, Ayer Neuroscience Institute, West Hartford, Connecticut, USA.,Division of Health Psychology, The Institute of Living/Hartford Hospital, Hartford, Connecticut, USA.,Department of Neurology, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Stephanie Bakaysa
- Department of Maternal Fetal Medicine, Hartford Healthcare, West Hartford, Connecticut, USA
| | - Amy Johnson
- Department of Obstetrics and Gynecology, University of Connecticut School of Medicine, Farmington, Connecticut, USA.,Department of Obstetrics and Gynecology, Hartford HealthCare, West Hartford, Connecticut, USA
| | - Maria Veronesi
- Hartford Healthcare Headache Center, Ayer Neuroscience Institute, West Hartford, Connecticut, USA
| | - Anne Williamson
- Research Department, Hartford Hospital, Hartford, Connecticut, USA
| | - Brian Grosberg
- Hartford Healthcare Headache Center, Ayer Neuroscience Institute, West Hartford, Connecticut, USA.,Department of Neurology, University of Connecticut School of Medicine, Farmington, Connecticut, USA
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Crowe HM, Wesselink AK, Wise LA, Jick SS, Rothman KJ, Mikkelsen EM, Sørensen HT, Hatch EE. Pre-pregnancy migraine diagnosis, medication use, and spontaneous abortion: a prospective cohort study. J Headache Pain 2022; 23:162. [PMID: 36539705 PMCID: PMC9764528 DOI: 10.1186/s10194-022-01533-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 12/08/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Migraine is common among females of reproductive age (estimated prevalence:17-24%) and may be associated with reproductive health through underlying central nervous system excitability, autoimmune conditions, and autonomic dysfunction. We evaluated the extent to which pre-pregnancy migraine diagnosis and medication use are associated with risk of spontaneous abortion (SAB). METHODS We analyzed data from a preconception study of pregnancy planners (2013-2021). Eligible participants self-identified as female, were aged 21-45 years, resided in the USA or Canada, and conceived during follow-up (n = 7890). Participants completed baseline and bimonthly follow-up questionnaires for up to 12 months or until a reported pregnancy, whichever occurred first. Pregnant participants then completed questionnaires during early (~ 8-9 weeks) and late (~ 32 weeks) gestation. We defined migraineurs as participants who reported a migraine diagnosis or use of a medication to treat migraine. Preconception questionnaires elicited migraine medication use during the past 4 weeks, and SAB on follow-up and pregnancy questionnaires. We used Cox regression models with gestational weeks as the time scale to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for associations among preconception migraine, migraine medication use, and SAB, controlling for potential demographic, medical, and lifestyle confounders. RESULTS Nineteen percent of study pregnancies ended in SAB. History of migraine before conception was not appreciably associated with SAB risk (HR = 1.03, 95% CI: 0.91-1.06). Use of any migraine medication was associated with a modest increase in SAB risk overall (HR = 1.14, 95% CI: 0.96-1.36). We observed the greatest increase in risk among those taking migraine medications daily (HR = 1.38, 95% CI: 0.81-2.35) and those taking prescription migraine prophylaxis (HR = 1.43, 95% CI: 0.72-2.84) or combination analgesic and caffeine medications (HR = 1.42, 95% CI: 0.99-2.04). CONCLUSIONS Migraine medication use patterns suggesting greater underlying migraine severity were associated with increased risk of SAB. This research adds to the limited information available on the reproductive effects of migraine.
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Affiliation(s)
- Holly M. Crowe
- grid.189504.10000 0004 1936 7558Harvard T.H. Chan School of Public Health, Department of Epidemiology, 677 Huntington Avenue, Boston, MA 02115 USA ,grid.189504.10000 0004 1936 7558Boston University School of Public Health, Department of Epidemiology, 715 Albany Street, Boston, MA 02118 USA
| | - Amelia K. Wesselink
- grid.189504.10000 0004 1936 7558Boston University School of Public Health, Department of Epidemiology, 715 Albany Street, Boston, MA 02118 USA
| | - Lauren A. Wise
- grid.189504.10000 0004 1936 7558Boston University School of Public Health, Department of Epidemiology, 715 Albany Street, Boston, MA 02118 USA
| | - Susan S. Jick
- grid.189504.10000 0004 1936 7558Boston University School of Public Health, Department of Epidemiology, 715 Albany Street, Boston, MA 02118 USA
| | - Kenneth J. Rothman
- grid.189504.10000 0004 1936 7558Boston University School of Public Health, Department of Epidemiology, 715 Albany Street, Boston, MA 02118 USA
| | - Ellen M. Mikkelsen
- grid.7048.b0000 0001 1956 2722Aarhus University, Department of Clinical Epidemiology, Olof Palmes Allé 43-45, DK-8200 Aarhus N, Denmark
| | - Henrik T. Sørensen
- grid.7048.b0000 0001 1956 2722Aarhus University, Department of Clinical Epidemiology, Olof Palmes Allé 43-45, DK-8200 Aarhus N, Denmark
| | - Elizabeth E. Hatch
- grid.189504.10000 0004 1936 7558Boston University School of Public Health, Department of Epidemiology, 715 Albany Street, Boston, MA 02118 USA
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Yamaguchi Y, Yamada T, Goto M, Kawasaki H, Wada T, Ikeda-Sakai Y, Saito Y, Hayashi M, Tanaka S, Takahashi R, Nakayama T, Murashima A, Kosugi S. Analysis of triptan use during pregnancy in Japan: A case series. Congenit Anom (Kyoto) 2022; 62:78-81. [PMID: 34981573 DOI: 10.1111/cga.12456] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 11/27/2021] [Accepted: 12/06/2021] [Indexed: 11/26/2022]
Abstract
To evaluate the safety of triptan use during pregnancy in a Japanese population, we descriptively analyzed the data on pregnancy and fetal outcomes from 128 pregnant women using triptans for migraine treatment at two Japanese facilities that provided counseling on drug exposure in pregnancy between 2001 and 2017. The risks of miscarriage, low birth weight, and preterm birth were similar to those reported in the demographic statistics in Japan. The incidence proportion of malformation was also within the baseline risk range. Accumulated data suggest that exposure to triptans during pregnancy does not clearly increase the risk of negative pregnancy and fetal outcomes. This finding can help reduce anxiety in pregnant women with migraines who are taking triptans.
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Affiliation(s)
- Yuko Yamaguchi
- Department of Medical Ethics and Medical Genetics, Kyoto University School of Public Health, Kyoto, Japan.,Department of Neurology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takahiro Yamada
- Department of Medical Ethics and Medical Genetics, Kyoto University School of Public Health, Kyoto, Japan
| | - Mikako Goto
- National Center for Child Health and Development, The Japan Drug Information Institute in Pregnancy, Tokyo, Japan
| | - Hidenori Kawasaki
- Department of Medical Ethics and Medical Genetics, Kyoto University School of Public Health, Kyoto, Japan
| | - Takahito Wada
- Department of Medical Ethics and Medical Genetics, Kyoto University School of Public Health, Kyoto, Japan
| | - Yasuko Ikeda-Sakai
- Department of Neurology, Kyoto University Graduate School of Medicine, Kyoto, Japan.,Department of Health Informatics, Graduate School of Medicine and School of Public Health, Kyoto University, Kyoto, Japan
| | - Yoshiyuki Saito
- Department of Health Informatics, Graduate School of Medicine and School of Public Health, Kyoto University, Kyoto, Japan
| | | | - Shiro Tanaka
- Department of Clinical Biostatistics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Ryosuke Takahashi
- Department of Neurology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takeo Nakayama
- Department of Health Informatics, Graduate School of Medicine and School of Public Health, Kyoto University, Kyoto, Japan
| | - Atsuko Murashima
- National Center for Child Health and Development, The Japan Drug Information Institute in Pregnancy, Tokyo, Japan
| | - Shinji Kosugi
- Department of Medical Ethics and Medical Genetics, Kyoto University School of Public Health, Kyoto, Japan
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15
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González-García N, Díaz de Terán J, López-Veloso AC, Mas-Sala N, Mínguez-Olaondo A, Ruiz-Piñero M, Gago-Veiga AB, Santos-Lasaosa S, Viguera-Romero J, Pozo-Rosich P. Headache: pregnancy and breastfeeding Recommendations of the Spanish Society of Neurology's Headache Study Group. Neurologia 2022; 37:1-12. [PMID: 31047730 DOI: 10.1016/j.nrl.2018.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 12/22/2018] [Indexed: 01/31/2023] Open
Abstract
INTRODUCTION Headache is one of the most common neurological complaints, and is most frequent during reproductive age. As a result, we are routinely faced with pregnant or breastfeeding women with this symptom in clinical practice. It is important to know which pharmacological choices are the safest, which should not be used, and when we should suspect secondary headache. To this end, the Spanish Society of Neurology's Headache Study Grouphas prepared a series of consensus recommendations on the diagnostic and therapeutic algorithms that should be followed during pregnancy and breastfeeding. DEVELOPMENT This guide was prepared by a group of young neurologists with special interest and experience in headache, in collaboration with the Group's Executive Committee. Recommendations focus on which drugs should be used for the most frequent primary headaches, both during the acute phase and for prevention. The second part addresses when secondary headache should be suspected and which diagnostic tests should be performed in the event of possible secondary headache during pregnancy and breastfeeding. CONCLUSIONS We hope this guide will be practical and useful in daily clinical practice and that it will help update and improve understanding of headache management during pregnancy and breastfeeding, enabling physicians to more confidently treat these patients.
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Affiliation(s)
| | - J Díaz de Terán
- Unidad de Cefaleas, Servicio de Neurología, Hospital Universitario La Paz, IdiPAZ, Instituto de Investigación Sanitaria, Madrid, España
| | - A C López-Veloso
- Servicio de Neurología, Hospital Universitario de Gran Canaria Dr. Negrín, Gran Canaria, España
| | - N Mas-Sala
- Servicio de Neurología, Hospital Universitario Sant Joan de Déu, Fundación Althaia, Manresa, Barcelona, España
| | - A Mínguez-Olaondo
- Servicio de Neurología, Hospital Universitario Donostia, Donostia, España; Servicio de Neurología, Clínica Universidad de Navarra, Pamplona, España
| | - M Ruiz-Piñero
- Servicio de Neurología, Hospital Universitario San Juan de Alicante, Alicante, España
| | - A B Gago-Veiga
- Unidad de Cefaleas, Servicio de Neurología, Instituto de Investigación Sanitaria Princesa, Hospital Universitario de la Princesa, Madrid, España
| | - S Santos-Lasaosa
- Unidad de Cefaleas, Servicio de Neurología, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
| | - J Viguera-Romero
- Unidad Gestión Clínica de Neurología, Hospital Virgen Macarena, Sevilla, España
| | - P Pozo-Rosich
- Unidad de Cefalea, Servicio de Neurología, Hospital Universitari Vall d'Hebron, Barcelona, España, Grupo de Investigación en Cefalea, VHIR, Universitat Autònoma Barcelona, España
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Abstract
Globally, headache disorders are an important cause of disability in adults. As many types of headache (eg, migraine, tension-type and medication-overuse) are more common in women and have peak incidence in reproductive years, chronic headache disorders are highly prevalent in pregnant women. Some women with a history of migraine may find that it improves during pregnancy while others may find that their migraines become more unpredictable. Ideally, women with migraine and problematic headache disorder should be offered preconception counselling to address pregnancy-related concerns and advice on the use of medicines, which should be supported by high-quality information. For women with history of headache, the use of effective non-pharmacological options should be maximised, and the smallest number of the safest medicines at the lowest effective doses should be used while preparing for pregnancy and during pregnancy. This article forms part of the series of prescribing for pregnancy and discusses the impact of headache and migraine on pregnancy, the impact of pregnancy on headache and migraine and options for prophylaxis and treatment.
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Affiliation(s)
- Caroline Ovadia
- Department of Women and Children's Health, King's College London, London, UK
- Obstetrics and Gynaecology, Guy's and St Thomas' NHS Foundation Trust, London, UK
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17
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Bérard A, Strom S, Zhao JP, Kori S, Albrecht D. Dihydroergotamine and triptan use to treat migraine during pregnancy and the risk of adverse pregnancy outcomes. Sci Rep 2021; 11:19302. [PMID: 34588467 PMCID: PMC8481540 DOI: 10.1038/s41598-021-97092-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 08/06/2021] [Indexed: 11/20/2022] Open
Abstract
Migraine is prevalent during pregnancy. Antimigraine medications such as dihydroergotamine (DHE) and triptans have been associated with adverse pregnancy outcomes in individual studies but lack of consensus remains. We compared the risk of prematurity, low birth weight (LBW), major congenital malformations (MCM), and spontaneous abortions (SA) associated with gestational use of DHE or triptans. Three cohort and one nested-case–control analyses were conducted within the Quebec Pregnancy Cohort to assess the risk of prematurity, LBW, MCM, and SA. Exposure was defined dichotomously as use of DHE or triptan during pregnancy. Generalized estimation equations were built to quantify the associations, adjusting for potential confounders. 233,900 eligible pregnancies were included in the analyses on prematurity, LBW, and MCM; 29,104 cases of SA were identified. Seventy-eight subjects (0.03%) were exposed to DHE and 526 (0.22%) to triptans. Adjusting for potential confounders, DHE and triptans were associated with increased risks of prematurity, LBW, MCM, and SA but not all estimates were statistically significant. DHE was associated with the risk of prematurity (aRR: 4.12, 95% CI 1.21–13.99); triptans were associated with the risk of SA (aOR: 1.63, 95% CI 1.34–1.98). After considering maternal migraine, all antimigraine specific medications increased the risk of some adverse pregnancy outcomes, but estimates were unstable.
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Affiliation(s)
- Anick Bérard
- Faculty of Pharmacy, University of Montreal, Montreal, QC, H3T 1J4, Canada. .,Research Center, CHU Sainte-Justine, Montreal, QC, H3T 1C5, Canada. .,Faculty of Medicine, Université Claude Bernard, Lyon 1, 69622, Lyon, France.
| | - Shannon Strom
- Satsuma Pharmaceuticals, Inc, San Francisco, CA, 94080, USA
| | - Jin-Ping Zhao
- Research Center, CHU Sainte-Justine, Montreal, QC, H3T 1C5, Canada
| | - Shashi Kori
- Satsuma Pharmaceuticals, Inc, San Francisco, CA, 94080, USA
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18
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Headache: pregnancy and breastfeeding. Recommendations of the Spanish Society of Neurology's Headache Study Group. NEUROLOGÍA (ENGLISH EDITION) 2021; 37:1-12. [PMID: 34535428 DOI: 10.1016/j.nrleng.2018.12.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 12/22/2018] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Headache is one of the most common neurological complaints, and is most frequent during reproductive age. As a result, we are routinely faced with pregnant or breastfeeding women with this symptom in clinical practice. It is important to know which pharmacological choices are the safest, which should not be used, and when we should suspect secondary headache. To this end, the Spanish Society of Neurology's Headache Study Group has prepared a series of consensus recommendations on the diagnostic and therapeutic algorithms that should be followed during pregnancy and breastfeeding. DEVELOPMENT This guide was prepared by a group of young neurologists with special interest and experience in headache, in collaboration with the Group's Executive Committee. Recommendations focus on which drugs should be used for the most frequent primary headaches, both during the acute phase and for prevention. The second part addresses when secondary headache should be suspected and which diagnostic tests should be performed in the event of possible secondary headache during pregnancy and breastfeeding. CONCLUSIONS We hope this guide will be practical and useful in daily clinical practice and that it will help update and improve understanding of headache management during pregnancy and breastfeeding, enabling physicians to more confidently treat these patients.
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19
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Ducros A, de Gaalon S, Roos C, Donnet A, Giraud P, Guégan-Massardier E, Lantéri-Minet M, Lucas C, Mawet J, Moisset X, Valade D, Demarquay G. Revised guidelines of the French headache society for the diagnosis and management of migraine in adults. Part 2: Pharmacological treatment. Rev Neurol (Paris) 2021; 177:734-752. [PMID: 34340810 DOI: 10.1016/j.neurol.2021.07.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 07/09/2021] [Indexed: 12/21/2022]
Abstract
The French Headache Society proposes updated French guidelines for the management of migraine. This article presents the second part of the guidelines, which is focused on the pharmacological treatment of migraine, including both the acute treatment of attacks and the prophylaxis of episodic migraine as well as chronic migraine with and without medication overuse. The specific situations that can be encountered in women with migraine are also discussed, including pregnancy, menstrual migraine, contraception and hormonal replacement therapy.
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Affiliation(s)
- A Ducros
- Department of neurology, Gui-de-Chauliac hospital, CHU Montpellier, university of Montpellier, 34000 Montpellier, France
| | - S de Gaalon
- Department of neurology, Laënnec hospital, CHU de Nantes, Nantes, France
| | - C Roos
- Emergency headache center (centre d'urgences céphalées), department of neurology, Lariboisière hospital, Assistance publique-Hôpitaux de Paris, Paris, France
| | - A Donnet
- Centre d'évaluation et de traitement de la douleur, FHU INOVPAIN, hôpital de La Timone, Marseille, France
| | - P Giraud
- Department of neurology, Annecy Genevois hospital, Annecy, France
| | | | - M Lantéri-Minet
- Pain department, FHU InovPain, CHU Nice Côte Azur université, Nice, France
| | - C Lucas
- Centre d'évaluation et de traitement de la douleur, service de neurochirurgie, hôpital Salengro, CHRU de Lille, Lille, France
| | - J Mawet
- Emergency headache center (centre d'urgences céphalées), department of neurology, Lariboisière hospital, Assistance publique-Hôpitaux de Paris, Paris, France
| | - X Moisset
- Neuro-Dol, université Clermont Auvergne, CHU de Clermont-Ferrand, INSERM, Clermont-Ferrand, France
| | - D Valade
- Department of neurosurgery, hôpital Pitié-Sapêtrière, Paris, France
| | - G Demarquay
- Neurological hospital, Lyon, neuroscience research center (CRNL), INSERM U1028, CNRS UMR5292, Lyon, France.
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20
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[Pain management during pregnancy : An expert-based interdisciplinary consensus recommendation]. Schmerz 2021; 35:382-390. [PMID: 34324048 PMCID: PMC8613155 DOI: 10.1007/s00482-021-00571-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2021] [Indexed: 11/29/2022]
Abstract
Hintergrund Schwangerschaft und Schmerzen unterschiedlicher Herkunft sind eine ungünstige Kombination, die alle BehandlerInnen vor besondere Herausforderungen stellt. Schmerzen beeinflussen die Homöostase des Menschen negativ. Compliance der Patientin und fundiertes Wissen über Fetotoxizität und Teratogenität von Analgetika sind nötig, um die Balance zwischen Therapie der Mutter und Sicherheit des Ungeborenen zu wahren. Ziel der Arbeit ExpertInnen verschiedener Disziplinen, die mit der Betreuung von schwangeren Schmerzpatientinnen betraut sind, haben sich zusammengeschlossen, um medikamentöse und nichtmedikamentöse Therapiekonzepte zu erstellen, mit dem Ziel, eine suffiziente Analgesie von schwangeren Schmerzpatientinnen zu ermöglichen. Material und Methode Relevante Fragestellungen wurden durch ExpertInnen formuliert und einer Literatursuche unterzogen. Kombiniert mit weiteren nationalen und internationalen Empfehlungen wurden Behandlungskonzepte entwickelt, interdisziplinär diskutiert und im Anschluss Kernaussagen erstellt, die mit Empfehlungsgraden abgestuft wurden. Ergebnisse Abhängig vom Trimenon können bei Schmerzen Paracetamol, Ibuprofen, Diclofenac, Metamizol und Opioide wohlüberlegt verabreicht werden, besondere Vorsicht ist bei nichtsteroidalen Antirheumatika (NSAR) im letzten Trimenon geboten. COX-2-Hemmer werden nicht empfohlen. Bei neuropathischen Schmerzen gelten Amitriptylin, Duloxetin, Venlafaxin als sicher. Bei starker Migräne kann Sumatriptan zum Einsatz kommen. Nichtmedikamentöse Therapien wie transkutane elektrische Nervenstimulation (TENS-Therapie), Kinesio-Tapes und Akupunktur gelten als sicher. Lymphdrainagen werden bei Ödemen empfohlen, sofern sie nicht durch eine Präeklampsie bedingt sind. Schlussfolgerung Die Therapie sollte mit einer nichtmedikamentösen Behandlung beginnen und eskalierend in einer Kombination aus medikamentösen und nichtmedikamentösen Konzepten enden.
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21
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Update on Management of Acute Migraine. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2021. [DOI: 10.1007/s40138-021-00235-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Paškevičiūtė E, Bužinskienė D, Ryliškienė K. De novo Migraine with Aura in the Third Trimester of Pregnancy: A Case Report and Literature review. Acta Med Litu 2021; 28:145-152. [PMID: 34393637 PMCID: PMC8311834 DOI: 10.15388/amed.2021.28.1.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 04/28/2021] [Accepted: 04/28/2021] [Indexed: 11/22/2022] Open
Abstract
Background Among all headache disorders, migraine has the highest prevalence during gestation. The majority of migraineurs experience improvement during pregnancy, but a few may experience migraine for the first time. This poses a diagnostic challenge in the differential diagnosis between primary and life-threatening secondary headache disorders. Because pregnancy itself is an independent risk factor for secondary headache disorders, it is mandatory to exclude these conditions in order to diagnose migraine. There is a large body of literature about pre-existing migraine course during pregnancy and its link with adverse pregnancy outcomes, but there are no studies examining these aspects among women with new-onset migraine during pregnancy. Case report A 31-year-old female at 33 weeks of gestation (gravida 2, para 2) was referred to the neurologist eds disturbances, which were followed by pressing severe headache, rated as 8 out of 10 on a numeric rating scale and accompanied by dizziness. The headache lasted for one day, and dizziness continued to the following day. The patient was investigated for a secondary headache disorder, but laboratory and neuroimaging results were unremarkable. A migraine with aura was diagnosed. The patient was advised to keep a consistent sleep schedule, maintain regular low physical activity, eat regularly and take magnesium supplementation. The patient was informed about a safe treatment approach in case of an acute attack. At 40 weeks of gestation the patient delivered female newborn, weighing 3750g, with Apgar scores of 8 and 9 (due to a nuchal cord). The postpartum period was uneventful. During the subsequent 4 years, the patient did not experience any recurrent migraine attacks and had no pregnancies. Conclusion In order to diagnose a migraine during pregnancy, exclusion of secondary headache disorders is mandatory. Pregnant migraineur should be regularly monitored for adverse birth outcomes. It is essential to educate patients, provide information about the safe treatment of migraine attacks, and explain nonpharmacological prevention and supplementation benefits.
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Affiliation(s)
- Elena Paškevičiūtė
- ORCID: https://orcid.org/0000-0002-1847-5640Vilnius University, Faculty of Medicine, Vilnius, Lithuania
| | - Diana Bužinskienė
- ORCID: https://orcid.org/0000-0002-4522-0600Clinic of Obstetrics and Gynaecology, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, LithuaniaCentre of Obstetrics and Gynaecology, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Kristina Ryliškienė
- ORCID: https://orcid.org/0000-0001-9596-1733Department of Neurology and Neurosurgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
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Latour M. [Use of triptans during pregnancy]. ACTA ACUST UNITED AC 2021; 49:564-566. [PMID: 33819673 DOI: 10.1016/j.gofs.2021.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 04/01/2021] [Indexed: 11/25/2022]
Abstract
Despite the widespread use of triptans in the treatment of migraine during pregnancy, questions relating to their vasoconstrictive properties have been raised following recent reports of rare fetal deaths and intrauterine growth restrictions. However, to date, analysis of these data does not allow to conclude to a direct effect of triptans, which remain a second line treatment of migraine attacks during pregnancy at any term and under normal conditions of use.
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Affiliation(s)
- M Latour
- Centre de référence sur les Agents Tératogènes (CRAT), Paris, France; DMU ESPRIT (épidémiologie et biostatistique, santé publique, pharmacie, pharmacologie, recherche, information médicale, thérapeutique et médicaments), Paris, France; GHU, Sorbonne Université - Site Trousseau, AP-HP, 26, avenue du Docteur Arnold Netter, 75571 Paris cedex 12, France.
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A systematic review and meta-analyses on the prevalence of pregnancy outcomes in migraine treated patients: a contribution from the IMI2 ConcePTION project. J Neurol 2021; 269:742-749. [PMID: 33792783 DOI: 10.1007/s00415-021-10534-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 03/23/2021] [Accepted: 03/24/2021] [Indexed: 12/25/2022]
Abstract
The present study aims to summarize the safety profile of the medications used to treat migraine during pregnancy by performing a systematic review and meta-analyses. The term "migrain*" combined with pregnancy terms were used to search Embase, PubMed, PsychInfo, Scopus, and Web of Science through 31 December 2020. Pooled prevalences of untreated and treated migraine patients were estimated using MetaXL software. Pooled odds ratios (OR) using random effects models were estimated in RevMan 5. All the identified studies assessed medications used to treat acute migraine. The pooled prevalence of adverse pregnancy outcomes in patients prescribed any migraine medication ranged from 0.4% (95% CI 0.2-0.7%) for stillbirth to 12.0% (95%CI 7.8-16.9%) for spontaneous abortions. Among untreated patients with migraine, the pooled prevalence of the assessed pregnancy outcomes ranged from 0.6% (95% CI: 0-1.7%) for stillbirth to 10.4% (95% CI: 8.9-12%) for gestational age < 37 weeks. Given the limited data, it was only possible to perform OR meta-analyses for triptans. The adjusted ORs for triptan users compared the general population were: for major malformations 1.07 (95%CI: 0.83-1.39, p = 0.60); birth weight < 2500g 1.18 (95%CI: 0.94-1.48, p = 0.16); gestational age < 37 weeks 1.49 (95% CI: 0.37-6.08, p = 0.58). In conclusion, triptans do not appear to increase the risk of pregnancy outcomes when compared to the general population. It was not possible to assess other migraine medications. Further studies are needed to investigate the safety of individual medications of acute and prophylactic migraine treatment among pregnant women.
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Hessler A. Women's and Fetal Issues in Neurotoxicology. Neurol Clin 2021; 38:897-912. [PMID: 33040868 DOI: 10.1016/j.ncl.2020.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Management of the pregnant patient with neurologic disease is challenging. Ideally, preconception planning can optimize the woman's neurologic condition before pregnancy. More than half of pregnancies are unplanned which makes careful consideration of medications vitally important. This article focuses on potential toxic risk to the fetus of medications deemed necessary to manage several common maternal neurologic issues: multiple sclerosis, epilepsy, and headache during pregnancy and postpartum. It is important for the practitioner to have an understanding beyond the category system to understand the potential toxic risks to the infant.
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Affiliation(s)
- Amy Hessler
- Neurology, University of Kentucky, 740 South Limestone, Lexington, KY 40536, USA.
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Saldanha IJ, Cao W, Bhuma MR, Konnyu KJ, Adam GP, Mehta S, Zullo AR, Chen KK, Roth JL, Balk EM. Management of primary headaches during pregnancy, postpartum, and breastfeeding: A systematic review. Headache 2021; 61:11-43. [PMID: 33433020 DOI: 10.1111/head.14041] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 10/28/2020] [Accepted: 11/16/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Primary headaches (migraine, tension headache, cluster headache, and other trigeminal autonomic cephalgias) are common in pregnancy and postpartum. It is unclear how to best and most safely manage them. OBJECTIVE We conducted a systematic review (SR) of interventions to prevent or treat primary headaches in women who are pregnant, attempting to become pregnant, postpartum, or breastfeeding. METHODS We searched Medline, Embase, Cochrane CENTRAL, CINAHL, ClinicalTrials.gov, Cochrane Database of SRs, and Epistemonikos for primary studies of pregnant women with primary headache and existing SRs of harms in pregnant women regardless of indication. No date or language restrictions were applied. We assessed strength of evidence (SoE) using standard methods. RESULTS We screened 8549 citations for studies and 2788 citations for SRs. Sixteen studies (mostly high risk of bias) comprising 14,185 patients (total) and 26 SRs met the criteria. For prevention, we found no evidence addressing effectiveness. Antiepileptics, venlafaxine, tricyclic antidepressants, benzodiazepines, β-blockers, prednisolone, and oral magnesium may be associated with fetal/child adverse effects, but calcium channel blockers and antihistamines may not be (1 single-group study and 11 SRs; low-to-moderate SoE). For treatment, combination metoclopramide and diphenhydramine may be more effective than codeine for migraine or tension headache (1 randomized controlled trial; low SoE). Triptans may not be associated with fetal/child adverse effects (8 nonrandomized comparative studies; low SoE). Acetaminophen, prednisolone, indomethacin, ondansetron, antipsychotics, and intravenous magnesium may be associated with fetal/child adverse effects, but low-dose aspirin may not be (indirect evidence; low-to-moderate SoE). We found insufficient evidence regarding non-pharmacologic treatments. CONCLUSIONS For prevention of primary headache, calcium channel blockers and antihistamines may not be associated with fetal/child adverse effects. For treatment, combination metoclopramide and diphenhydramine may be more effective than codeine. Triptans and low-dose aspirin may not be associated with fetal/child adverse effects. Future research should identify effective and safe interventions in pregnancy and postpartum.
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Affiliation(s)
- Ian J Saldanha
- Center for Evidence Synthesis in Health, Department of Health Services, Policy, and Practice, Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Wangnan Cao
- Center for Evidence Synthesis in Health, Department of Health Services, Policy, and Practice, Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Monika Reddy Bhuma
- Center for Evidence Synthesis in Health, Department of Health Services, Policy, and Practice, Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Kristin J Konnyu
- Center for Evidence Synthesis in Health, Department of Health Services, Policy, and Practice, Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Gaelen P Adam
- Center for Evidence Synthesis in Health, Department of Health Services, Policy, and Practice, Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Shivani Mehta
- Center for Evidence Synthesis in Health, Department of Health Services, Policy, and Practice, Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Andrew R Zullo
- Center for Evidence Synthesis in Health, Department of Health Services, Policy, and Practice, Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA.,Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Kenneth K Chen
- Department of Medicine, Warren Alpert Medical School, Brown University, Providence, RI, USA.,Department of Obstetrics and Gynecology, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Julie L Roth
- Department of Neurology, Brown University Warren Alpert Medical School, Providence, RI, USA
| | - Ethan M Balk
- Center for Evidence Synthesis in Health, Department of Health Services, Policy, and Practice, Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
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Noseda R, Bedussi F, Gobbi C, Zecca C, Ceschi A. Safety profile of erenumab, galcanezumab and fremanezumab in pregnancy and lactation: Analysis of the WHO pharmacovigilance database. Cephalalgia 2021; 41:789-798. [PMID: 33435709 DOI: 10.1177/0333102420983292] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To assess the safety profile of erenumab, galcanezumab and fremanezumab in pregnancy and lactation. METHODS Safety reports of suspected adverse drug reactions were retrieved from VigiBase as of 31 December 2019, for a case-by-case assessment and disproportionality analysis using the reporting odds ratio (ROR). RESULTS There were 94 safety reports: 50 (53.2%) on erenumab, 31 (33.0%) on galcanezumab, and 13 (13.8%) on fremanezumab. In five (5.3%) safety reports, drug exposure occurred prior to pregnancy, in 85 (90.4%) during pregnancy, in one (1.1%) during lactation, in one (1.1%) via paternal exposure, and in two (2.1%) the exposure time was unknown. Out of 94 safety reports, 51 (54.3%) consisted only of drug exposure, while 43 (45.7%) additionally reported 47 adverse drug reactions including maternal toxicities (n = 18), poor breastfeeding (n = 1), spontaneous abortion (n = 23), preterm birth/prematurity (n = 3), and birth defects (n = 2). There was no signal of disproportionate reporting for spontaneous abortion compared to the full database (reporting odds ratio 1.46, 95% confidence interval 0.97-2.20). When triptans were used as a comparator group, a signal of disproportionate reporting for spontaneous abortion was detected in association with erenumab, galcanezumab, and fremanezumab (reporting odds ratio 1.86, 95% confidence interval 1.12-3.13), which was not statistically significant after excluding confounded safety reports (reporting odds ratio 1.21, 95% confidence interval 0.67-2.21). CONCLUSIONS No specific maternal toxicities, patterns of major birth defects, or increased reporting of spontaneous abortion were found. However, because of the relatively limited number of adverse drug reactions reported and the lack of long-term safety data, continuous surveillance is required in pregnant and lactating women exposed to these drugs.
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Affiliation(s)
- Roberta Noseda
- Division of Clinical Pharmacology and Toxicology, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Francesca Bedussi
- Division of Clinical Pharmacology and Toxicology, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Claudio Gobbi
- Neurocenter of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland.,Faculty of Biomedical Sciences, University of Southern Switzerland, Lugano, Switzerland.,Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Chiara Zecca
- Neurocenter of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland.,Faculty of Biomedical Sciences, University of Southern Switzerland, Lugano, Switzerland
| | - Alessandro Ceschi
- Division of Clinical Pharmacology and Toxicology, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland.,Faculty of Biomedical Sciences, University of Southern Switzerland, Lugano, Switzerland.,Department of Clinical Pharmacology and Toxicology, University Hospital Zurich, Zurich, Switzerland
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28
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Hamilton KT, Halker Singh RB, Ailani J, Butterfield RJ, Robbins MS. Migraine Treatment in Pregnancy: An American Headache Society Survey. Headache 2020; 60:2594-2596. [DOI: 10.1111/head.13974] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 08/06/2020] [Indexed: 01/29/2023]
Affiliation(s)
| | | | - Jessica Ailani
- Department of Neurology Georgetown University Washington DC USA
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Medicines for headache before and during pregnancy: a retrospective cohort study (ATENA study). Neurol Sci 2020; 42:1895-1921. [PMID: 32968869 PMCID: PMC8043957 DOI: 10.1007/s10072-020-04702-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 08/29/2020] [Indexed: 12/28/2022]
Abstract
Objective To investigate headache treatment before and during pregnancy. Background Most headaches in pregnancy are primary disorders. Headaches are likely to ameliorate during pregnancy, although they may also begin or worsen. Most headache medications should be avoided during pregnancy because of potential fetal risks. However, only scarce evidence on headache drug consumption during pregnancy is available. Design ATENA was a retrospective, self-administered questionnaire-based, cohort study on women in either pregnancy or who have just delivered and reporting headache before and/or during pregnancy. Results Out of 271 women in either pregnancy or who have just delivered, 100 (37%) reported headache before and/or during pregnancy and constituted our study sample. Before pregnancy, the attitude toward the use of symptomatic drugs was characterized by both a strong focus on their safety and the willingness to avoid possible dependence from them. Compared to the year before, pregnancy led to changes in behavior and therapeutic habits as shown by a higher proportion of patients looking for information about drugs (44/100 [44%] vs. 36/100 [36%]) and a lower proportion of those treating headache attacks (88/100 [88%] vs. 52/100 [52%]) and by a lower use of nonsteroidal anti-inflammatory drugs (68/100 [68%] vs. 5/100 [5%]) and a much higher use of paracetamol (33/100 [33%] vs. 95/100 [95%]). Conclusions Pregnancy changes how women self-treat their headache, and leads to search for information regarding drug safety, mostly due to the perception of fetal risk of drugs. Healthcare providers have to be ready to face particular needs of pregnant women with headache. Electronic supplementary material The online version of this article (10.1007/s10072-020-04702-0) contains supplementary material, which is available to authorized users.
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30
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de Gaalon S, Donnet A. Headaches during pregnancy. Rev Neurol (Paris) 2020; 177:195-202. [PMID: 32838992 DOI: 10.1016/j.neurol.2020.05.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 05/20/2020] [Accepted: 05/25/2020] [Indexed: 12/31/2022]
Abstract
Headache during pregnancy is frequent and challenging. A secondary headache is diagnosed in one third of women, and most causes are vascular and infectious disorders. Anamnestic and clinical features must be investigated, and brain imaging is often required. Primary headaches are commonly modified during pregnancy. Migraine is mainly improved in this context, especially migraine without aura. Particular cautions about treatment must be applied, and non-pharmacological measures must be preferred. Tension-type headache and cluster headache seem to be less hormone-dependent.
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Affiliation(s)
- S de Gaalon
- Service de neurologie, hôpital Laënnec, CHU de Nantes, Nantes, France.
| | - A Donnet
- Centre d'évaluation et de traitement de la douleur, FHU INOVPAIN, hôpital de La Timone, Marseille, France
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31
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van Casteren DS, van den Brink AM, Terwindt GM. Migraine and other headache disorders in pregnancy. HANDBOOK OF CLINICAL NEUROLOGY 2020; 172:187-199. [PMID: 32768088 DOI: 10.1016/b978-0-444-64240-0.00011-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Migraine prevalence is three times higher in women than in men during fertile years, which is mainly due to sex hormone differences. The majority of women suffering from migraine without aura report improvement of their migraine attacks during pregnancy. Migraine attacks with aura can also improve during pregnancy, but more often remain the same or worsen. Anovulation caused by lactation is generally associated with a decrease in migraine attacks in breastfeeding women. This chapter describes the current knowledge on acute and prophylactic treatment options of migraine and other primary headache disorders during pregnancy and lactation. Further, clinical profiles of secondary headaches during pregnancy and the postpartum period are summarized.
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Affiliation(s)
- Daphne S van Casteren
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands; Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | - Gisela M Terwindt
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands.
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32
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Use of triptans during pregnancy? With caution! Therapie 2019; 76:477-478. [PMID: 31924306 DOI: 10.1016/j.therap.2019.12.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 10/22/2019] [Accepted: 12/12/2019] [Indexed: 12/20/2022]
Abstract
We report cases, registered in the French national pharmacovigilance database, of fetal death and intrauterine growth retardation in women exposed to triptans during pregnancy. Triptans have vasoconstrictive properties and we wonder about their responsibility for these side effects. The use of triptans and other drugs exhibiting vasoconstrictive properties in pregnant women requires a careful benefits/risks evaluation.
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Abstract
Migraine affects 959 million people worldwide,1 with the highest prevalence being in women of childbearing age. The interplay between female hormones and migraine can be a challenging area to navigate since issues relating to pregnancy, contraception and the menopause are often out of the neurology comfort zone. This review aims to help the neurologist to manage women with migraine, from menarche to menopause.
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34
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Burch R. Epidemiology and Treatment of Menstrual Migraine and Migraine During Pregnancy and Lactation: A Narrative Review. Headache 2019; 60:200-216. [DOI: 10.1111/head.13665] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/19/2019] [Indexed: 12/11/2022]
Affiliation(s)
- Rebecca Burch
- John R. Graham Headache Center, Department of Neurology Brigham and Women's Hospital, Harvard Medical School Boston MA USA
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35
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Abstract
Migraine is a lifelong condition that disproportionately affects women and, if not effectively managed, can lead to significant disability. It is important for clinicians to have a good understanding of the impact of the hormonal fluctuations that occur throughout a female migraineur's life, so that appropriate, stratified therapies can be implemented. In doing so, whether it is migraine onset at menarche in an adolescent young woman, or migraine worsening in a perimenopausal female migraineur, quality of life can be ensured.
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36
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Halker Singh RB, Ailani J, Robbins MS. Neuromodulation for the Acute and Preventive Therapy of Migraine and Cluster Headache. Headache 2019; 59 Suppl 2:33-49. [DOI: 10.1111/head.13586] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2019] [Indexed: 12/15/2022]
Affiliation(s)
| | - Jessica Ailani
- Department of Neurology Georgetown University Washington DC USA
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37
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Karpova MI, Zariada AA, Dolgushina VF, Korotkova DG, Ekusheva EV, Osipova VV. [Migraine in women: clinical and therapeutical aspects]. Zh Nevrol Psikhiatr Im S S Korsakova 2019; 119:98-107. [PMID: 31089104 DOI: 10.17116/jnevro201911903198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Migraine is one of the most common neurological disorders, affecting women. Physiological changes in the hormonal status can modulate the functional status of pain and analgesic systems of the brain and, by involving different pathophysiological mechanisms, change the course of migraine. In addition to an analysis of epidemiological data, the review provides current views on the clinical features of the disease in women population at different periods of life, particular attention was focused on menstrual migraine. It has certain features, such as acute and long attacks and treatment difficulties. One of main issues is the use of oral contraceptives in women with migraine according to the ratio of potential benefit to cardiovascular risk. The problems of treatment headaches in pregnant and breastfeeding women are also considered. An influence of migraine on the course and outcome of pregnancy was shown. The authors analysed the results of the studies on the course of migraine during perimenopause and postmenopause and recommendations for women with migraine attacks and climacteric syndrome. The data presented in the review are useful for clinicians, because this information represents new views on pathogenetic mechanisms, clinical features and treatment of migraine in women.
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Affiliation(s)
- M I Karpova
- South Ural State Medical University, Russian Ministry of Health, Chelyabinsk
| | - A A Zariada
- South Ural State Medical University, Russian Ministry of Health, Chelyabinsk
| | - V F Dolgushina
- South Ural State Medical University, Russian Ministry of Health, Chelyabinsk
| | - D G Korotkova
- South Ural State Medical University, Russian Ministry of Health, Chelyabinsk
| | - E V Ekusheva
- Academy of Postgraduate Education under FSBU FSCC of FMBA of Russia, Moscow, Russia
| | - V V Osipova
- Research Department of Neurology, Research-technological park of Biomedicine, Sechenov First Moscow State Medical University; Moscow Research Clinical Centre for Neuropsychiatry, Moscow Health Department, Moscow, Russia
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38
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Skajaa N, Szépligeti SK, Xue F, Sørensen HT, Ehrenstein V, Eisele O, Adelborg K. Pregnancy, Birth, Neonatal, and Postnatal Neurological Outcomes After Pregnancy With Migraine. Headache 2019; 59:869-879. [PMID: 31069791 DOI: 10.1111/head.13536] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2019] [Indexed: 01/03/2023]
Abstract
BACKGROUND Prevalence of migraine is high during the reproductive age. Although migraine often improves during pregnancy, the risk of adverse pregnancy, birth, neonatal, and neurological outcomes in mother and offspring remains poorly understood. OBJECTIVE To investigate the associations between maternal migraine and risks of adverse pregnancy outcomes in the mother, and birth, neonatal and postnatal outcomes in the offspring. METHODS We used Danish population registries to assemble a cohort of pregnancies among women with migraine and an age- and conception year-matched comparison cohort of pregnancies among women without migraine. The study period was 2005-2012. We computed adjusted prevalence ratios (aPRs) for pregnancy and birth outcomes and adjusted risk ratios (aRRs) for neonatal and postnatal outcomes, adjusting for age, preconception medical history, and preconception reproductive history. RESULTS We identified 22,841 pregnancies among women with migraine and 228,324 matched pregnancies among women without migraine. Migraine was associated with an increased risk of pregnancy-associated hypertension disorders (aPR: 1.50 [95% confidence interval (CI): 1.39-1.61]) and miscarriage (aPR: 1.10 [95% CI: 1.05-1.15]). Migraine was associated with an increased prevalence of low birth weight (aPR: 1.14 [95% CI: 1.06-1.23]), preterm birth (aPR: 1.21 [95% CI: 1.13-1.30]) and cesarean delivery (aPR: 1.20 [95% CI: 1.15-1.25]), but not of small for gestational age offspring (aPR: 0.94 [95% CI: 0.88-0.99]) and birth defects (aPR: 1.01 [95% CI: 0.93-1.09]). Offspring prenatally exposed to maternal migraine had elevated risks of several outcomes in the neonatal and postnatal period, including intensive care unit admission (aRR: 1.22 [95% CI: 1.03-1.45]), hospitalization (aRR: 1.12 [95% CI: 1.06-1.18]), dispensed prescriptions (aRR: 1.34 [95% CI: 1.24-1.45]), respiratory distress syndrome (aRR: 1.20 [95% CI: 1.02-1.42]), and febrile seizures (aRR: 1.27 [95% CI: 1.03-1.57), but not of death (aRR: 0.67 [95% CI: 0.43-1.04]) and cerebral palsy (aRR: 1.00 [95% CI: 0.51-1.94]). CONCLUSIONS Women with migraine and their offspring have greater risks of several adverse pregnancy outcomes than women without migraine.
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Affiliation(s)
- Nils Skajaa
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark
| | | | - Fei Xue
- Center for Observational Research, Amgen Inc., Thousand Oaks, CA, USA
| | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark
| | - Vera Ehrenstein
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark
| | - Osa Eisele
- Global Patient Safety and Labeling, Amgen Inc., Thousand Oaks, CA, USA
| | - Kasper Adelborg
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark.,Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus N, Denmark
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39
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Hudon Thibeault AA, Sanderson JT, Vaillancourt C. Serotonin-estrogen interactions: What can we learn from pregnancy? Biochimie 2019; 161:88-108. [PMID: 30946949 DOI: 10.1016/j.biochi.2019.03.023] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 03/28/2019] [Indexed: 02/07/2023]
Abstract
We have reviewed the scientific literature related to four diseases in which to serotonin (5-HT) is involved in the etiology, herein named 5-HT-linked diseases, and whose prevalence is influenced by estrogenic status: depression, migraine, irritable bowel syndrome and eating disorders. These diseases all have in common a sex-dimorphic prevalence, with women more frequently affected than men. The co-occurrence between these 5-HT-linked diseases suggests that they have common physiopathological mechanisms. In most 5-HT-linked diseases (except for anorexia nervosa and irritable bowel syndrome), a decrease in the serotonergic tone is observed and estrogens are thought to contribute to the improvement of symptoms by stimulating the serotonergic system. Human pregnancy is characterized by a unique 5-HT and estrogen synthesis by the placenta. Pregnancy-specific disorders, such as hyperemesis gravidarum, gestational diabetes mellitus and pre-eclampsia, are associated with a hyperserotonergic state and decreased estrogen levels. Fetal programming of 5-HT-linked diseases is a complex phenomenon that involves notably fetal-sex differences, which suggest the implication of sex steroids. From a mechanistic point of view, we hypothesize that estrogens regulate the serotonergic system, resulting in a protective effect against 5-HT-linked diseases, but that, in turn, 5-HT affects estrogen synthesis in an attempt to retrieve homeostasis. These two processes (5-HT and estrogen biosynthesis) are crucial for successful pregnancy outcomes, and thus, a disruption of this 5-HT-estrogen relationship may explain pregnancy-specific pathologies or pregnancy complications associated with 5-HT-linked diseases.
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Affiliation(s)
- Andrée-Anne Hudon Thibeault
- INRS-Institut Armand-Frappier, 531, boulevard des Prairies, Laval, QC, H7V 1B7, Canada; Center for Interdisciplinary Research on Well-Being, Health, Society and Environment (Cinbiose), Université du Québec à Montréal, C.P.8888, succ. Centre-Ville, Montréal, QC, H3C 3P8, Canada.
| | - J Thomas Sanderson
- INRS-Institut Armand-Frappier, 531, boulevard des Prairies, Laval, QC, H7V 1B7, Canada.
| | - Cathy Vaillancourt
- INRS-Institut Armand-Frappier, 531, boulevard des Prairies, Laval, QC, H7V 1B7, Canada; Center for Interdisciplinary Research on Well-Being, Health, Society and Environment (Cinbiose), Université du Québec à Montréal, C.P.8888, succ. Centre-Ville, Montréal, QC, H3C 3P8, Canada.
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40
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Cem Kaplan Y, Juch H. Letter to editor: comment on 'The need for contraception in patients taking prescription drugs: a review of FDA warning labels, duration of effects, and mechanisms of action' by Zhang et al. Expert Opin Drug Saf 2019; 18:339-340. [PMID: 30822388 DOI: 10.1080/14740338.2019.1587887] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Yusuf Cem Kaplan
- a Department of Pharmacology , Izmir Katip Celebi University School of Medicine , Izmir, Turkey.,b Training and Research Center , Terafar-Izmir Katip Celebi University Teratology Information , Izmir , Turkey
| | - Herbert Juch
- c Department of Cell Biology , Gottfried Schatz Research Center for Cell Signaling, Metabolism and Aging, Medical University Graz , Graz , Austria
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41
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42
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Diener HC, Holle-Lee D, Nägel S, Dresler T, Gaul C, Göbel H, Heinze-Kuhn K, Jürgens T, Kropp P, Meyer B, May A, Schulte L, Solbach K, Straube A, Kamm K, Förderreuther S, Gantenbein A, Petersen J, Sandor P, Lampl C. Treatment of migraine attacks and prevention of migraine: Guidelines by the German Migraine and Headache Society and the German Society of Neurology. CLINICAL AND TRANSLATIONAL NEUROSCIENCE 2019. [DOI: 10.1177/2514183x18823377] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
In collaboration with some of the leading headache centres in Germany, Switzerland and Austria, we have established new guidelines for the treatment of migraine attacks and the prevention of migraine. A thorough literature research of the last 10 years has been the basis of the current recommendations. At the beginning, we present therapeutic novelties, followed by a summary of all recommendations. After an introduction, we cover topics like drug therapy and practical experience, non-effective medication, migraine prevention, interventional methods, non-medicational and psychological methods for prevention and therapies without proof of efficacy.
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Affiliation(s)
- Hans-Christoph Diener
- Klinik für Neurologie und Westdeutsches Kopfschmerzzentrum, Universitätsklinikum Essen, Essen, Germany
| | - Dagny Holle-Lee
- Klinik für Neurologie und Westdeutsches Kopfschmerzzentrum, Universitätsklinikum Essen, Essen, Germany
| | - Steffen Nägel
- Klinik für Neurologie und Westdeutsches Kopfschmerzzentrum, Universitätsklinikum Essen, Essen, Germany
| | - Thomas Dresler
- Klinik für Psychiatrie und Psychotherapie, Universität Tübingen, Tübingen, Germany
- Graduiertenschule & Forschungsnetzwerk LEAD, Universität Tübingen, Tübingen, Germany
| | - Charly Gaul
- Migräne- und Kopfschmerzklinik Königstein, Königstein im Taunus, Germany
| | | | | | - Tim Jürgens
- Universitätsmedizin Rostock, Zentrum für Nervenheilkunde, Klinik und Poliklinik für Neurologie, Rostock, Germany
| | - Peter Kropp
- Institut für Medizinische Psychologie und Medizinische Soziologie, Universitätsmedizin Rostock, Zentrum für Nervenheilkunde, Rostock, Germany
| | - Bianca Meyer
- Institut für Medizinische Psychologie und Medizinische Soziologie, Universitätsmedizin Rostock, Zentrum für Nervenheilkunde, Rostock, Germany
| | - Arne May
- Institut für Systemische Neurowissenschaften, Universitätsklinikum Hamburg Eppendorf (UKE), Hamburg, Germany
| | - Laura Schulte
- Institut für Systemische Neurowissenschaften, Universitätsklinikum Hamburg Eppendorf (UKE), Hamburg, Germany
| | - Kasja Solbach
- Klinik für Neurologie, Universitätsklinikum Essen, Essen, Germany
| | - Andreas Straube
- Neurologische Klinik, Ludwig-Maximilians-Universität München, Klinikum Großhadern, München, Germany
| | - Katharina Kamm
- Neurologische Klinik, Ludwig-Maximilians-Universität München, Klinikum Großhadern, München, Germany
| | - Stephanie Förderreuther
- Neurologische Klinik, Ludwig-Maximilians-Universität München, Klinikum Großhadern, München, Germany
| | | | - Jens Petersen
- Klinik für Neurologie, Universitätsspital Zürich, Zürich, Swizterland
| | - Peter Sandor
- RehaClinic Bad Zurzach, Bad Zurzach, Swizterland
| | - Christian Lampl
- Ordensklinikum Linz, Krankenhaus der Barmherzigen Schwestern Linz Betriebsgesellschaft m.b.H., Linz, Austria
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Zidverc-Trajković J. Pharmacotherapy of the most frequent headaches in adults. ARHIV ZA FARMACIJU 2019. [DOI: 10.5937/arhfarm1901032z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Hamilton KT, Robbins MS. Migraine Treatment in Pregnant Women Presenting to Acute Care: A Retrospective Observational Study. Headache 2018; 59:173-179. [PMID: 30403400 DOI: 10.1111/head.13434] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2018] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To assess the acute treatment of pregnant women presenting to a hospital with migraine. BACKGROUND Migraine is a common problem in pregnancy; however, migraine treatment is challenging in pregnant women for fears of medication teratogenicity and lack of data in this population. To date, no study has directly explored physician practices for treatment of acute migraine in pregnant women. METHODS We conducted a retrospective chart review of medication administration for pregnant women who presented to an acute care setting with a migraine attack and received neurology consultation between 2009 and 2014. RESULTS We identified 72 pregnant women with migraine who were treated with pain medications. Fifty-one percent (37/72) were in the third trimester of pregnancy, 39% (28/72) in the second trimester, and 10% (7/72) in the first trimester. Thirty-two percent (23/72) had not tried any acute medications at home before coming to the hospital, and 47% (34/72) presented in status migrainosus. Patients received treatment in the hospital for a median of 23 hours (interquartile range = 5-45 hours). The most common medications prescribed were metoclopramide in 74% (53/72) of patients (95% confidence interval [CI] 62-82%) and acetaminophen in 69% (50/72) of patients (95% CI 58-79%). Metoclopramide was administered along with diphenhydramine in 81% (44/53) of patients (95% CI 71-91%). Acetaminophen was the most frequent medicine administered first (53%, 38/72). Patients were often treated with butalbital (35%, 25/72) or opioids (30%, 22/72), which were used as second- or third-line treatments in 29% of patients (20/72). Thirty-eight percent (27/72) received an intravenous (IV) fluid bolus, 24% received IV magnesium (17/72), and 6% (4/72) had peripheral nerve blocks performed. CONCLUSIONS While the majority of pregnant women with acute migraine received medications considered relatively safe in pregnancy, there was variation in treatment choice and sequence. Some acute medications considered potentially hazardous for fetal health and less effective for migraine (opioids and butalbital) were used frequently, whereas other treatments that may have low teratogenic risk (nerve blocks, IV fluid boluses, and triptans) were used less or not at all. These results indicate a need for developing guidelines and protocols to standardize acute treatment of migraine in pregnancy.
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Affiliation(s)
- Katherine T Hamilton
- Department of Neurology, Montefiore Headache Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Matthew S Robbins
- Department of Neurology, Montefiore Headache Center, Albert Einstein College of Medicine, Bronx, NY, USA
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Abstract
PURPOSE OF REVIEW Migraine is a debilitating disease, that is encountered in countless medical offices every day and since it is highly prevalent in women, it is imperative to have a clear understanding of how to manage migraine. There is a growing body of evidence regarding the patterns we see in women throughout their life cycle and how we approach migraine diagnosis and treatment at those times. RECENT FINDINGS New guidelines regarding safety of medication during pregnancy and lactation are being utilized to help guide management decisions in female migraineurs. There is also new data surrounding the risk of stroke in individuals who suffer from migraine with aura. This article seeks to provide an overview of a woman's migraine throughout her lifetime, the impact of hormones and an approach to management.
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Affiliation(s)
- Candice Todd
- Toronto Western Hospital, The University of Toronto, University Health Network, 399 Bathurst St. 5WW441, Toronto, ON, M5T 2S8, Canada
| | - Ana Marissa Lagman-Bartolome
- Centre for Headache, Women's College Hospital, The University of Toronto, 76 Grenville Street, 3rd floor, Toronto, ON, M5S 1B2, Canada
| | - Christine Lay
- Centre for Headache, Women's College Hospital, The University of Toronto, 76 Grenville Street, 3rd floor, Toronto, ON, M5S 1B2, Canada.
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Harris GME, Wood M, Ystrom E, Nordeng H. Prenatal triptan exposure and neurodevelopmental outcomes in 5-year-old children: Follow-up from the Norwegian Mother and Child Cohort Study. Paediatr Perinat Epidemiol 2018; 32:247-255. [PMID: 29569251 DOI: 10.1111/ppe.12461] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Triptans are commonly used to treat migraine headaches, but data on the long-term safety of these medications during pregnancy are sparse. Triptans have a biologically plausible mechanism for effects on the fetal brain through binding to 5-HT1 -receptors, and previous studies show increased risks of externalising behaviour problems in toddlers exposed to triptans during pregnancy. METHODS We included 3784 children in the Norwegian Mother and Child Cohort Study, whose mothers returned the 5-year-questionnaire and reported a history of migraine or triptan use; 353 (9.3%) mothers reported use of triptans during pregnancy, 1509 (39.9%) reported migraine during pregnancy but no triptan use, and 1922 (50.8%) had migraine prior to pregnancy only. We used linear and log-binomial models with inverse probability weights to examine the association between prenatal triptan exposure and internalising and externalising behaviour, communication, and temperament in 5-year-old children. RESULTS Triptan-exposed children scored higher on the sociability trait than unexposed children of mothers with migraine (β 1.66, 95% confidence interval [0.30, 3.02]). We found no other differences in temperament, or increased risk of behaviour or communication problems. CONCLUSIONS Contrary to results from previous studies in younger children, we found no increased risk of externalising behaviour problems in 5-year-old children exposed to triptans in fetal life. Triptan-exposed children did have slightly more sociable temperaments, but the clinical meaning of this finding is uncertain.
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Affiliation(s)
- Gerd-Marie Eskerud Harris
- Pharmacoepidemiology & Drug Safety Research Group, School of Pharmacy, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
| | - Mollie Wood
- Pharmacoepidemiology & Drug Safety Research Group, School of Pharmacy, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
| | - Eivind Ystrom
- Pharmacoepidemiology & Drug Safety Research Group, School of Pharmacy, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway.,Department of Mental Disorders, Norwegian Institute of Public Health, Oslo, Norway.,Department of Psychology, University of Oslo, Oslo, Norway
| | - Hedvig Nordeng
- Pharmacoepidemiology & Drug Safety Research Group, School of Pharmacy, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway.,Department of Child Health and Development, Norwegian Institute of Public Health, Oslo, Norway
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Afridi SK. Current concepts in migraine and their relevance to pregnancy. Obstet Med 2018; 11:154-159. [PMID: 30574176 DOI: 10.1177/1753495x18769170] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 03/01/2018] [Indexed: 12/12/2022] Open
Abstract
The prevalence of migraine in women of childbearing age is high, estimated at 24%. Migraine management during pregnancy and lactation can be challenging. Our understanding of the way in which medications affect the unborn fetus is still incomplete and the evidence is constantly changing with more recent emphasis on longitudinal studies and childhood development. The aim of this article is to describe the relationship between migraine and pregnancy and review the current evidence on treatment options in pregnancy and lactation.
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Affiliation(s)
- Shazia K Afridi
- Department of Neurology, Guy's and St Thomas' NHS Trust, London, UK
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Zidverc-Trajković J. Pharmacotherapy of the most frequent headaches in adults. ARHIV ZA FARMACIJU 2018. [DOI: 10.5937/arhfarm1806032z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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