Abstract
This little book does what it says on the cover and guides the reader through the non-pharmacological and drug treatments for migraine that are thought to be safe to use in pregnancy and breastfeeding. It comes with a CD-ROM included.
However, before the meat of the main chapters the authors outline the pathophysiology of migraine and the normal course of migraines in pregnancy. They write authoritatively as practising clinicians and always approach their subject from the patient's point of view. Throughout the book, the reader is directed to numerous helpful online resources and websites for both patients and clinicians. The CD-ROM contains printable materials such as headache diaries and patient education sheets ready for use in outpatient clinics. Each chapter starts with Key Chapter Points and is punctuated throughout with ‘Pearls for the Practitioner’. While useful, this results in the text being somewhat repetitive, especially since we are reminded about non-drug approaches for dealing with headaches in virtually every chapter. I am not disputing the importance of non-pharmacological strategies, and indeed learnt a lot about lifestyle triggers, psychological pain management skills, and exercise and physical therapy, but with such a thorough review in a dedicated chapter, there seemed no need to repeatedly cover these issues in each chapter. One often got the impression that the intended audience for this book was more the patients themselves and the lay reader rather than clinicians.
With regard to drug therapy, this is an American book and unsurprisingly as such relies pretty much on the Food and Drug Administration (FDA) classification system to rank ‘safety’. For the treatment sections, the recommendations were fairly standard – paracetemol/acetaminophen and caffeine with triptans if benefit outweighs risk in pregnancy and the addition of non-steroidal anti-inflammatory drugs during lactation. However, the recommendations for antinausea drugs and preventive drugs were somewhat more controversial. I found it very surprising, for example, that for migraine prevention gabapentin use in the first trimester was thought to be safer than amitriptyline and that low-dose aspirin did not receive a mention. For nausea, the authors recommend ondansetron as the first-line antiemetic in pregnancy and during breastfeeding.
The latest (eighth) edition of Drugs in Pregnancy and Lactation by Briggs, Freeman and Yaffe (a text referenced by the authors) raises concerns of drug-induced developmental toxicity with gabapentin monotherapy and describes a similar phenotype and congenital malformations as with other antiepileptic drugs (AEDs). Indeed, all the AEDs have been shown to be teratogenic. Amitriptyline, also FDA category C, is described by Briggs, Freeman and Yaffe as relatively safe in pregnancy – not least of all because there is a wealth of experience of tricyclic use in pregnancy. In general, in obstetric medicine the older more established drugs are preferred and certainly in the UK, we would use amitriptyline before gabapentin if prophylaxis with propranolol was ineffective. Similarly, although data suggest that ondansetron (FDA category B) use is safe in pregnancy, we would opt for metoclopramide (also FDA B) or prochlorperazine (FDA C) or promethazine (FDA C) first.
The penultimate chapter is an excellent review of ‘Work-up for headache during pregnancy and lactation’. The authors discuss the differential diagnosis of headache in pregnancy and postpartum, explaining the importance of consideration of secondary causes and describing the appropriate investigation of acute headache. Here the authors are to be congratulated for a balanced and evidence-based summary of the issues, particularly concerning neuroimaging and radiological investigations in pregnancy. This remains a very real problem for all of us having weekly conversations with radiologists who insist magnetic resonance imaging with contrast, i.e. gadolinium, be withheld in pregnancy. The authors review the literature and state clearly that gadolinium is considered safe for the developing baby.
Overall I enjoyed reading this book and would recommend it to others. Its strengths are the patient-focused approach and useful signposting to internet resources regarding migraine and drug treatments in pregnancy and during lactation. Its weaknesses are the parochial nature of some of the recommendations and the fact that the information could have been presented using half the number of pages.