EXECUTIVE SUMMARY
A two-part Association of Reproductive Health Professionals webinar series, “Migraines & the Female Patient,” offers information on the epidemiology of migraines and how to counsel affected women on their contraceptive options.
- The diagnosis of a migraine requires the presence of two of four criteria: unilateral location, pulsating/throbbing nature of pain, at least moderate intensity, and aggravation by or preference to avoid activity. It also requires nausea or a combination of both photophobia and phonophobia with the episode. The last criterion can be established by the individual’s simple preference to avoid bright lights and loud noises during an attack.
- Steady or rising concentrations of estrogen do not precipitate a migraine, but the steep decline in estrogen levels that occurs prior to menstruation can precipitate unusually severe attacks that are known as menstrual-related migraines.
What do you know when it comes to prescribing combined hormonal methods for women with migraines? A new two-part Association of Reproductive Health Professionals webinar series, “Migraines & the Female Patient,” offers information on the epidemiology of migraines and how to counsel affected women on their contraceptive options.
The two-part event is presented by Pelin Batur, MD, FACP, NCMP, CCD, an internist at the Cleveland (OH) Clinic, and Anne Calhoun, MD, FAHS, the co-founder of the Carolina Headache Institute in Durham, NC, and a professor in the departments of anesthesiology and psychiatry at the University of North Carolina at Chapel Hill. To access the webinar series, readers can go to http://bit.ly/2aMa5NK. Select “Migraines in the Female Life-Cycle” to access links to the presentations.
Using criteria established in The International Classification of Headache Disorders, the diagnosis of a migraine requires the presence of two of four criteria: unilateral location, pulsating/throbbing nature of pain, at least moderate intensity, and aggravation by or preference to avoid activity.1 It also requires nausea or a combination of both photophobia and phonophobia with the episode. The last criterion can be established by the individual’s simple preference to avoid bright lights and loud noises during an attack.
Patients with a stable pattern of episodic, disabling headache and a normal physical exam should be considered to have a migraine in the absence of contradictory evidence.2,3 In a study of patients seeking care for their headaches from a primary care provider, more than 90% were diagnosed to have migraines or probable migraines as defined by standardized diagnostic criteria.4 In a large epidemiologic study, 30,758 adults were asked if they had headaches and, if so, how they would label them. Headaches were reported by 23,564 of the participants and subsequently were diagnosed by formal International Headache Society criteria. Among the 3,074 individuals who met the criteria for a migraine, about 50% correctly recognized their headaches as migraines; the most common erroneous labels were “sinus headache” and “stress headache.”5
To diagnose a migraine with aura, at least two attacks must be recognized, accompanied by fully reversible visual, sensory, and/or speech/language symptoms.1 At least one of these symptoms must be unilateral and spread gradually over five minutes; alternatively, two or more aura symptoms may occur in succession. Each individual aura symptom must last between five and 60 minutes, with the aura followed by the onset of a headache within 60 minutes.1 Blurring, floaters, or split-second flashes before or during a migraine headache do not meet criteria for aura.
Steady or rising concentrations of estrogen do not precipitate a migraine, but the steep decline in estrogen levels that occurs prior to menstruation can precipitate unusually severe attacks that are known as menstrual-related migraines, notes Calhoun. These attacks are often refractory to therapy.
Have a good strategy for addressing contraceptive choices in women with migraines, because most of them experience menstrual migraines, says Calhoun. “The best way to prevent menstrual migraine is simply by eliminating the hormonal trigger, which can be accomplished with the right choice of combined hormonal contraceptive,” notes Calhoun. “If the woman has migraine with aura, we now have a couple of contraceptives that can potentially decrease their aura frequency and, thereby, hopefully, decrease any stroke risk.”
Use of a combined hormonal contraceptive for migraines with aura remains controversial, due to data suggesting that aura increases stroke risk and that high-dose oral contraceptives increase stroke risk.6-8
While studies have shown that continuous use of combined oral contraceptives and use of combined pills that minimize drops in estrogen can help improve general headaches and menstrual-related migraines, such research has excluded patients who have migraines with aura.9,10 A small pilot study of women with migraines with aura and menstrual-related migraines was conducted, in which women were offered a vaginal ring that releases 15 µg ethinyl estradiol per 24 hours, with instructions to use the continuous ultra-low dose hormonal contraception without placebo days. After a mean follow-up of eight months, data indicate this regimen reduced aura frequency from a baseline average of 3.2 per month to 0.2 per month. No woman had an increase in aura frequency, and menstrual-related migraine was eliminated in 91.3% of the patients.11
Continuous or extended cycle regimens can be prescribed using any generic 20 µg combined hormonal contraceptive which the patient tolerates, along with specific instructions on the prescription to take the pills in a continuous fashion to decrease the frequency of menstrual-related migraines, advises Batur.
The just-released U.S. Medical Eligibility Criteria for Contraceptive Use, 2016 (US MEC 2016) lists the copper T and the levonorgestrel IUDs, the contraceptive shot, the contraceptive implant, and progestin-only pills as Category 1 (no restrictions on use) for women with migraines without aura and women with migraines with aura. Use of combined hormonal contraceptives in women with migraines without aura is classified as Category 2 (benefits generally outweigh risks), while use in women with migraines with aura is classified as Category 4 (condition represents unacceptable health risk if method is used.)12
This represents no change from the 2010 guidance, which also classified use of combined hormonal contraception for women of all ages with aura as a Category 4.13
REFERENCES
- Headache Classification Committee of the International Headache Society. The International Classification of Headache Disorders, third edition (beta version). Cephalalgia 2013; 33(9):629-808.
- Lipton RB, Cady RK, Stewart WF, et al. Diagnostic lessons from the Spectrum Study. Neurology 2002; 58:S27-31.
- Lipton RB, Stewart WF, Cady R, et al. 2000 Wolfe Award. Sumatriptan for the range of headaches in migraine sufferers: Results of the Spectrum Study. Headache 2000; 40:783-791.
- Tepper SJ, Dahlof CG, Dowson A, et al. Prevalence and diagnosis of migraine in patients consulting their physician with a complaint of headache: Data from the Landmark Study. Headache 2004; 44:856-864.
- Lipton RB, Stewart WF, Liberman JN. Self-awareness of migraine: Interpreting the labels that headache sufferers apply to their headaches. Neurology 2002; 58:S21-26.
- Oral contraceptives and stroke in young women. Associated risk factors. JAMA 1975; 231:718-722.
- Roach RE, Helmerhorst FM, Lijfering WM, et al. Combined oral contraceptives: The risk of myocardial infarction and ischemic stroke. Cochrane Database Syst Rev 2015; 8:CD011054.
- Donaghy M, Chang CL, Poulter N. Duration, frequency, recency, and type of migraine and the risk of ischaemic stroke in women of childbearing age. J Neurol Neurosurg Psychiatry 2002; 73:747-750.
- Sulak P, Willis S, Kuehl T, et al. Headaches and oral contraceptives: Impact of eliminating the standard 7-day placebo interval. Headache 2007; 47:27-37.
- Nappi RE, Terreno E, Sances G, et al. Effect of a contraceptive pill containing estradiol valerate and dienogest (E2V/DNG) in women with menstrually-related migraine (MRM). Contraception 2013; 88:369-375.
- Calhoun A, Ford S, Pruitt A. The impact of extended-cycle vaginal ring contraception on migraine aura: A retrospective case series. Headache 2012; 52:1246-1253.
- Curtis KM, Tepper NK, Jatlaoui TC, et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. MMWR Recomm Rep 2016; 65(3):1-103.
- CDC. U.S. Medical Eligibility Criteria for Contraceptive Use. MMWR 2010; 59(RR04):1-86.
