Hi Dr. Lawrence,

I suffer from migraines and was wondering what was the safest way for me to get relief with the least harm to my baby. I have fioricet with codeine and percoset. I plan to get regular fioricet, but for the future, I would like to know the following:

1. When acetominophen doesn't work - which is the best of the above for me to take and how bad is the codeine?

2. Would it be best for me to pump and discard that milk when the meds are in it and just bottle feed? I pump now so my husband can give our daughter a bottle in the evening and she does great with this.

3. How long does each med remain in the milk?

4. What are the possible side effects of these meds?

5. What is the latest about taking Zomig, Maxalt, and these types ?

I also have a broken tailbone from delivery that is ever so slowly healing. I take acetominophen for that when I have to, which is about 3x/week. I usually go lie down and rest on my side to get the pressure off the tailbone. I am a stay at home mom so I have that luxury. My OB said the pain can last for 6-9 months, but if I was still having problems he would refer me to an orthopedic surgeon and removal of tailbone may be indicated. What have you seen in your practice and what do you recommend?

The idea of surgery does not sound good with a young baby. In advance I can't thank you enough for your response and suggestions.
My main concern of course is the best thing for my baby. After years of infertility she is the focus of our lives and we cherish every minute
with her.

Sincerely,

Sherri
 

1. Fioricet is a mild sedative containing Butalbital, which is a mild, short-acting barbiturate that probably gets into milk in very low amounts. For the treatment of migraine if the mother is alert enough to breastfeed, it should not be a problem for the infant. If it is necessary to take multiple doses of this medication, then it would be important to be sure that the baby does not become sedated. One could always substitute a feeding of previously pumped milk or formula. Fioricet contains acetaminophen, caffeine, and butalbital. The caffeine will probably counter the butalbital effect. For brief periods of time, this drug would not be a problem.

2. Percocet is similar in that it has either acetaminophen or aspirin as a base and may contain codeine, but Percocet does not have any sedative in it. Codeine is usually safe with breastfeeding because infants do metabolize and excrete codeine well and of course adults excrete it very well. A dose or two of codeine-containing medications should not pose any problem for the nursing infant. If it is necessary to take codeine for several days, it would be important just to be sure that the infant is not sedated by it and continues to feed in the same feeding pattern as previously. It is always better to breastfeed first and then take a medication after the feeding is done to minimize the amount that gets in the breast milk. It should not be necessary to pump and discard your milk if you have been able to control your symptoms with a dose or two; however, if you are increasing the dose or taking several doses in a row, it might be appropriate to pump and discard two hours after the large dose. What you might do is pump and store some of your milk so if you're ever concerned or feel too ill to nurse the baby for a few hours, that your husband could feed the baby your previously pumped milk.

3. How long does each medication remain in the milk?  Acetaminophen is not a problem for the baby and its half-life in milk in hours is between 1.4 and 4.7 hours. Caffeine has a half-life of 2 to 10 hours. However, this should not be a problem for a 6-month-old child. Butalbital has a very extended half-life of 30 to 60 hours. The half-life of codeine in the milk is 2 to 2-1/2 hours.

4. The side effects of these medications have been discussed above.

5. What is the latest about taking Zomig, Sumatriptan, Maxalt:  Zomig is the trade name for Zolmitrittan. It is not known if it is excreted into the milk, athough its pharmacologic parameters would suggest that probably very little gets into the milk. Only about 50% of it is absorbed orally and of course the infant would get it orally in the milk so that decreases the risk. It is an ergotamine derivative so that it peaks in the mother's plasma 2 to 4 hours after ingestion. Because of the lack of information, it is not currently recommended. It is possible to pump and discard for the first four hours after a dose and breastfeed following that.

Sumatriptan, trade name for Imitrex, is a newer anti-migraine medication that is closer to the serotonin reuptake agonists. It has been studied during breastfeeding and a small amount does get into the milk. The total amount of drug found in the milk after a single dose was very small. This concentration in milk corresponded to an infant exposure of only 3.5% of mother's dose. The oral bioavailability is only 14%; thus, the infant would only absorb 0.5% of the mother's dose. Thus, it is not thought to be a risk to the suckling infant. The milk half-life is 2.2 hours. The concentrations in milk are very low.

Maxalt, trade name for Rivatrittan, is another anti-migraine drug that is an ergotmamine derivative, which does pose a problem for the breastfed infant. It is not known whether it appears in human milk. It is therefore too early to say whether it can safely be used during lactation. The half-life in the maternal plasma is 2 to 3 hours, therefore it would be possible to pump and discard the milk for the first 4 or 5 hours and then resume breastfeeding.

6. Regarding the broken tailbone and the pain from this, as mentioned
earlier, acetaminophen is quite safe as is ibuprofen and these can be taken in multiple doses. An additional drug known as Aleve (generic name, Naproxen) has been included on the list of drugs that can be safely used by breastfeeding mothers published by the American Academy of Pediatrics. A drug dose appears in milk in very small amounts and has not been observed to cause any difficulties. There are some drug cross-reactions with Naproxen but this would depend on the medication taken by the mother and would not effect the infant. Your physician can guide you on this question.

Dr. Ruth Lawrence, professor, author and researcher, serves on Breastfeeding.com's medical advisory board. Dr. Lawrence is a professor of pediatrics, obstetrics and gynecology at the University of Rochester. She is also director of the university's Breastfeeding and Human Lactation Study Center. Dr. Lawrence is the author of "Breastfeeding: A Guide for the Medical Profession," the standard medical reference book for breastfeeding. She was one of eight doctors who helped the American Academy of Pediatrics draft its 1997 policy statement supporting breastfeeding.

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