Graduate Student UNC Gillings School of Global Public Health UNC Gillings School of Global Public Health Chapel Hill, United States
Background: The primary prescription medications for the acute treatment of migraines outside of pregnancy are triptans. Safety data on triptans in pregnancy is limited but prior studies are relatively reassuring: prenatal triptan use is not associated with many common pregnancy safety outcomes such as preterm birth, major congenital malformations and spontaneous abortion. Even so, many pregnant migraineurs discontinue triptan use in the first trimester.
Objectives: We aimed to expand on prior literature by examining associations between first trimester triptan use and several pregnancy outcomes.
Methods: We identified a cohort of pregnant people within United States commercial insurance claims data from 2004-2015, whose pregnancy ended in a livebirth, stillbirth, termination, spontaneous abortion or unspecified abortion. We restricted this population to pregnancies that had an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) migraine diagnosis code at an inpatient, outpatient or emergency department visit in the 90 days prior to the last menstrual period (LMP) and filled a prescription for a triptan in the same window. To estimate the total effect of first trimester triptan usage we compared participants who had a 1st trimester (LMP + 97 days) triptan fill (continuers) to participants who did not have a 1st trimester triptan fill (discontinuers) using generalized linear models. We used inverse probability of treatment weights to account for differences in baseline characteristics including comorbidities, medication use, demographics, healthcare utilization and proxies of disease severity.
Results: Of the 8,329 pregnancies included in this analysis, 2,501 filled a triptan prescription in the first trimester. Triptan continuers had a decreased risk of preterm birth (risk ratio [RR] 0.74, 95% confidence interval [CI] 0.62, 0.89) and small for gestational age (SGA) (RR 0.82, 95% CI 0.54, 1.25). Risk was similar for postpartum hemorrhage (RR 0.9, 95% CI 0.53, 1.52), stillbirth (RR 0.75, 95% CI 0.28, 2.03), preeclampsia (0.99, 95% CI 0.79, 1.23) and placenta accreta spectrum (0.98, 95% CI 0.50, 1.91). We observed an increased risk of placental abruption (1.54, 95% CI 0.88, 2.68), and placenta previa (1.65, 95% CI 0.92, 2.95).
Conclusions: The results for preterm birth, SGA, postpartum hemorrhage, stillbirth, preeclampsia and placenta accreta spectrum were reassuring for pregnant migraineurs who need to continue triptans. However, continuation was associated with an increased risk of placental abruption and placenta previa which warrants increased attention.