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NEW ORLEANS – Monday's FDA announcement that pregnant women should not take valproate sodium and related drugs to prevent migraine during pregnancy didn't come as much of a surprise to ob/gyns gathered here for the American Congress of Obstetricians and Gynecologists annual meeting.

Nor was it surprising to internists and pain specialists, most of whom agreed that triptans are the go-to drugs for frequent or serious migraines in pregnancy.

Most said they don't even think of valproate as a treatment for migraines but rather as an anti-seizure medication. Plus, there are seven or eight medications that are better for treating migraine in pregnancy, they agreed.

Eric Lantzman, MD, an ob/gyn with a native-owned health system based in Anchorage, AK, said he has never prescribed valproate to a pregnant patient – "and wouldn't without a perinatalogist involved."

"Everybody knows [valproate] is a bad drug in pregnancy. Frankly, I was surprised it wasn't a category X (risks clearly outweigh any potential benefits) a long time ago," said Mark Green, MD, director of headache and pain medicine at Icahn School of Medicine at Mount Sinai in New York City.

That said, there are unique management difficulties posed by migraineurs who then become pregnant, as well as by women who first present with symptoms of migraine during pregnancy, Lantzman said.

"Straightforward migraines without any symptoms other than headache can usually be treated without involving a neurologist. But there are several ways in which migraines can complicate a pregnancy," he said.

For starters, headache is a hallmark symptom of preeclampsia, he noted. "So before even thinking migraine, we would want to check blood pressure and do a urinalysis to rule out preeclampsia," Lantzman said.

That holds true whether or not the patient has a history of migraines, he added.

If the patient has aura, stroke enters into the differential diagnosis, Lantzman said. While still rare, strokes are more common in pregnancy. And "missing a catastrophic event in a young generally healthy woman is just tragic," he said.

So how should migraine be treated in pregnancy?

"It may be as simple as recommending lifestyle changes to avoid triggers and Tylenol," Lantzman said.

Biofeedback and behavior modification may also help, according to Green.

Sharon Phelan, MD, an ob/gyn at the University of New Mexico in Albuquerque, said she first recommends "good hydration, good sleep, and low stress."

But for patients who can't be managed with those strategies, "the triptans are our go-to medication," Lantzman said.

"Triptans, that's what we use sporadically," said meeting program co-chair Laurie McKenzie, MD, of Houston IVF.

"Generally, we've been using more of the triptans, which are category C drugs (animal studies have shown adverse effects on the fetus, but studies on humans are inadequate or inconclusive)," Phelan said.

"We're not aware of the triptans having a major problem in pregnancy," she said. Still, "it is always a risk-benefit balance that you go through," she added.

Green said that while nothing is completely safe in pregnancy, he tends to prescribe amitriptyline or beta blockers for the patient with frequent migraines.

"And in a situation where women are very ill, I will use injectable sumatriptan. There are many triptans on the market, but [it is the] only injectable," he said.

Opiates or other narcotics may help with pain, several of the physicians told 番茄社区.

"But it is not something you want to do for just the occasional migraine that someone can manage otherwise. Pregnant women are just as likely to become opiate-dependent as non-pregnant women," Phelan said.

As a footnote, said Green, "Be aware that FDA labeling of X with Valproate applies to migraine, not for use in bipolar and epilepsy."

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