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Archive for October, 2008

The topic of migraine treatment and pregnancy has surfaced several times in the past few months. I had always thought I would blog about pregnancy and migraine at some point. I guess now is the time.
Some of the questions about pregnancy or the contemplation of starting a family center around medication. Depakote, or divalproate sodium, was recently approved for the prophylaxis of Migraine attacks. It can be extremely effective (long ago I was on Depakote and my migraine frequency went from nearly daily to no attacks!). It is also teratogenic and can cause severe cardiovascular anomalies and neural tube defects in infants exposed to valproate during the first trimester. The package insert warns patients of this danger.There is one flaw in the warning. The information in the package inserts was obtained from women who were being treated for epilepsy and not Migraine.
An Israeli study (Diav-Citrin, Schlectman, Bar-Oz, Cantrell, Arnon, & Ornoy, 2008) included all callers who contacted the Israeli Teratology Informations Service during 1994-2004 concerning gestational valproate exposure. From this initial population there were 154 valproate exposed pregnancies. This included women who were taking valproate for reasons other than epilepsy. The control group (1315 pregnancies) were people who were counseled for nonteratolgic concerns during the same time period.
The results showed that valproate exposure increased the risk of major anomalies 2-fold as compared with controls. When the valproate-exposed group was divided into subgroups (treated for epilepsy and treated for other medical problems), the authors found that all of the fetuses with major anamolies were found in the epilepsy group and had been exposed to valproate throughout the pregnancy. None of the women taking valproate for problems other than epilepsy had babies with birth defects.
What does this study mean to Migraineurs? Valproate is a known teratogen. That’s the bad news. However, this study seems to say that women whose valoproate doses are less than mg/day and includes another anticonvulsant. The authors stated, “[i]t was noteworthy that, in the present study, a daily valproate dose of less than 1000 mg was not associated with increased risk of major anomalies.” To me this is good news.
References: Diav-Citrin O., Schlectman, S., Bar-Oz, B., Cantrell, D., Arnon, J., & Ornoy, A. (2008). Pregnancy outcome after in utero exposure to valproate: Evidence of dose relationship in teratogenic effect. CNS Drugs, 22, 325-334. Picture courtesy of the Headache-Adviser.

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