Psy-Q: A patient with comorbid bipolar disorder, chronic migraine, and epilepsy is considering pregnancy. How can a clinician best manage medications? Lawrence Robbins, MD, answers

Lawrence Robbins MD

Lawrence Robbins, MD

Answer: Many conditions are associated with a slight increased risk of problems at birth and during childhood, including bipolar disorder, epilepsy, and migraine. When it comes to medication selection for individuals with bipolar disorder and medical comorbidities, multiple clinical considerations must be made.

Consider the following hypothetical case:

  •  A woman in her late 20s has had frequent depressive states since age 14. She was diagnosed at age 26 with bipolar disorder. She presents with depression in remission and is on quetiapine 50mg and lamotrigine 100mg, each once per day.
  • She reports moderate chronic migraine twice-weekly (severe once a month) and daily mild to moderate headache. She is on 8 OTC aspirin / acetaminophen (paracetamol) / caffeine tablets (Excedrin) daily. The patient has tonic-clonic epilepsy – diagnosed at age 12. Her seizures are infrequent, and lamotrigine has helped to stop her seizures. The patient also has moderate IBS-D.
  • Blood tests (including thyroid), neurology exam, and MRI are unremarkable.
  • The patient shares that she is thinking about getting pregnant.
  • See the full case.

While lamotrigine can be used to help treat the patient’s bipolar disorder, it does not usually alleviate migraine. The two anticonvulsants that consistently help to prevent migraine headaches are sodium valproate and topiramate. Topiramate is not an effective mood stabilizer, however, and may destabilize moods.  Sodium valproate would be an alternative if pregnancy was not possible. The risk of sodium valproate in pregnancy varies with the dose. For 750 mg or more, there is a 12% increased risk of birth defects. This percentage does decrease to 3% if low doses (250 to 500 mg) are utilized. If pregnancy is possible sodium valproate should not be recommended.

A diagnosis of epilepsy itself increases the risk of birth defects. Lamotrigine only incurs a slight increased risk. Oxcarbazepine appears to be slightly safer than carbamazepine during pregnancy. Topiramate imparts a milder increased risk, slightly more than does lamotrigine. While I would aim to avoid antidepressants in this case, if they were to be utilized, the risk during pregnancy should be a consideration and discussed with the patient.

With pregnancy, antidepressant use is associated with somewhat lower Apgar scores.  There is also a slight increased incidence of larger birth weight babies. SNRIs may raise blood pressure in the pregnant patient due to the norepinephrine present.  SSRIs taken during pregnancy may be associated with lower communication skills in the child at 12 months of age. There is a slight risk for language or cognition problems with SSRI use.

Cases like the one presented require careful consideration to weigh both the risks and benefits of pharmacologic options. In addition, regular psychotherapy should be made available to help the patient manage psychiatric symptoms related to bipolar disorder and chronic pain.




Last Updated: Jun 15, 2021