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Contraception options for migraine sufferers

In the third article in a series of five, migraine specialist Dr Anne MacGregor explores some dilemmas around contraception and family planning

In the third article in a series of five, migraine specialist Dr Anne MacGregor explores some dilemmas around contraception and family planning

For most women – including those with migraine – combined hormonal contraceptives (CHCs) are a highly effective and safe means of contraception and confer added health benefits. But for a minority with specific risk factors, including migraine with aura, CHCs are associated with added health risks.

Effect of CHCs on headache and migraine

• Compared with baseline, headache increases during the early cycles of CHC use, but improves with continued use.

• Women experiencing headache in the first cycle of CHCs have only a one in three chance of experiencing headache in the second cycle and a one in 10 chance in the third cycle.

• Women aged 35 or over, and those with a strong personal or family history of headaches, are more likely to report worsening or new onset of headache associated with CHCs.

• Neither the dose of ethinylestradiol nor the dose or type of progestogen appear to influence headache or migraine.

Effect of CHCs on migraine with aura

41217671• Migraine with aura is more likely to worsen following CHC use, and may appear for the first time.

• Use of CHCs is associated with a

1.5- to twofold increased risk of ischaemic stroke. Other independent risk factors for ischaemic stroke include:

– smoking

– hypertension

– migraine with aura (see box).

• Pre-existing migraine with aura is considered a contraindication to CHCs by most authorities (see box).

41217672• Women developing migraine aura associated with CHCs should immediately switch to a progestogen-only or non-hormonal method of contraception.

Migraine in the hormone-free interval

• Headache and migraine without aura related to CHC use are most likely to occur during the hormone-free interval, typically around the third day.

• The mechanism is typically oestrogen ‘withdrawal'.

• Changing from a 30-35µg ethinylestradiol method to a 20µg method has minimal effect, given that all low-dose CHCs substantially elevate oestrogen levels above normal levels.

• Effective methods to control headaches in the hormone-free interval include:

– 100µg oestrogen patches: first patch on day 21; replace with new patch on day

24 or 25 (third or fourth day of hormone-free interval); remove on first day of next CHC pack

– oestrogen supplements

– long-cycle CHCs – for example, running three or four packs together back to back before a seven-day break

– continuous running of CHCs without a break.

• There is increasing evidence of the benefits, safety and efficacy of continuous combined CHCs.

• Breakthrough bleeding can occur with continuous CHCs, but this typically resolves with continued use.

Effect of progestogen-only methods on migraine

Few studies differentiate between headache and migraine. Most cite incidence of headache only. Consequently, adverse events reporting headache will include migraine.

Progestogen-only contraception does not have any adverse effects on thrombotic parameters, and use of these methods is not associated with an increased risk of ischaemic stroke. Hence, they are safe and effective for women for whom oestrogen-containing methods are contraindicated.

Progestogen-only pill

Improvement is more likely in women who become amenorrhoeic. It may be necessary to double the dose (off licence) to achieve this.

Subdermal implants

Retrospective non-comparative studies suggest the reported incidence of headache is not increased among women using subdermal implants such as Implanon.

Depot progestogens

• Studies suggest there are no significant changes in headache from baseline in women using depot medoxyprogesterone acetate (DMPA).

• Anecdotally, headache can occur with breakthrough bleeding in early cycles of use and typically resolves once amenorrhoea is achieved.

Levonorgestrel IUS

• Headache is a common complaint in early months of use.

• Reported as a significant reason for removal compared with women using copper IUCDs (1.9% vs 0.25% at five years).

• There is evidence that headache in the early months of use can settle with continued use.

Effect of non-hormonal methods on migraine

• Headache is reported as an adverse event in trials of non-hormonal methods – which is not surprising as headache and migraine is a common complaint in all women.

• Anecdotally, ‘menstrual' headache is more common in women with dysmenorrhoea and menorrhagia, which occur in association with copper IUCDs.

Dr Anne MacGregor is director of clinical research at the City of London Migraine Clinic, London

This is an extract from Headache: A Practical Manual, by Dr David Kernick and Dr Peter Goadsby, published by Oxford University Press, ISBN 978-0-19-923259-8. Available from bookshops or online from Oxford University Press

CHC recommendations Risks Subdermal implants like Implanon do not increase the risk of headache Subdermal implants like Implanon do not increase the risk of headache

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