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Clinical Reviews


How to choose a contraceptive for a patient who has headaches

Developing an accurate diagnosis of headache subtype will help avert unnecessary restriction of hormonal methods among your patients who do not have “pure” migraine

February 2011 · Vol. 23, No. 2

IN THIS ARTICLE

RELATED ARTICLE

Headaches are highly prevalent in women during their reproductive years. Most are a painful nuisance and do not present a risk of serious morbidity. Some, however, can be dangerous, and the addition of an estrogen-containing contraceptive can increase that risk.

Combination estrogen-progestin contraceptives are effective, popular, and easy to use—but are they safe for women who have headaches? This is a critical question. Some women who have preexisting headaches experience relief with hormonal contraception; others report stable or worsening symptoms; still others do not develop headaches until they begin hormonal contraception.

The differentiation between nuisance and true medical risk in this population depends on an accurate diagnosis of headache subtype. Taking a few moments to confirm whether a patient with headache has a true risk if she chooses hormonal contraception will prevent unnecessary restriction of a method and promote contraceptive success.

In this article, we present three cases that facilitate discussion of the safety, adverse effects, and benefits of various contraceptive strategies in women who have headaches.

Many women who report migraines don’t have them

Most women who report headaches to their gynecologist have not received a clinical diagnosis of headache subtype. They may say that they have “migraines” because that is the term used most commonly in the United States to indicate a severe level of distress with a headache. In actuality, although migraine is common in women, tension-type headaches are more prevalent.

The evaluation of a patient with headaches who is seeking contraception should begin with a simple diagnostic algorithm for headache type. Accurate diagnosis can be made using the International Headache Society (IHS) comprehensive guide for headache subtypes, last updated in 2004.1 TABLE 1, presents a simple classification of chronic headache syndromes, which account for more than 90% of headaches.

TABLE 1

Diagnostic criteria for headache subtypes

Tension-type

Infrequent episodic

A.

At least 10 episodes <1 day per month on average (<12 days per year) and fulfilling criteria B–D below

Frequent episodic

A.

At least 10 episodes occurring ≥1 but <15 days per month for at least 3 months (≥12 and <180 days per year) and fulfilling criteria B–D

B.

Headache lasting for 30 minutes to 7 days

C.

Headache has at least two of the following characteristics:

  1. bilateral location
  2. pressing/tightening (nonpulsating) quality
  3. mild or moderate intensity
  4. not aggravated by routine physical activity such as walking or climbing stairs

D.

Both of the following:

  1. no nausea or vomiting (anorexia may occur)
  2. no more than one of photophobia or phonophobia

E.

Not attributable to another disorder

Cluster

A.

At least 5 attacks fulfilling criteria B–D

B.

Severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting 15–180 minutes if untreated

C.

Headache is accompanied by at least one of the following:

  1. ipsilateral conjunctival injection and/or lacrimation
  2. ipsilateral nasal congestion and/or rhinorrhea
  3. ipsilateral eyelid edema
  4. ipsilateral forehead and facial sweating
  5. ipsilateral miosis and/or ptosis
  6. a sense of restlessness or agitation

D.

Attacks have a frequency from one every other day to 8 per day

E.

Not attributable to another disorder

Migraine without aura

At least 5 attacks fulfilling criteria B–D

A.

Headache attacks lasting 4–72 hours (untreated or successfully treated)

B.

Headache has at least two of the following characteristics:

  1. unilateral location
  2. pulsating quality
  3. moderate or severe pain intensity
  4. aggravation by or causing avoidance of routine physical activity (e.g., walking or climbing stairs)

C.

During headache at least one of the following:

  1. nausea and/or vomiting
  2. photophobia and phonophobia

D.

Not attributable to another disorder

Typical migraine with aura headache

A.

At least 2 attacks fulfilling criteria B–D

B.

Aura consisting of at least one of the following, but no motor weakness:

  1. fully reversible visual symptoms including positive features (e.g., flickering lights, spots, or lines) and/or negative features (e.g., loss of vision)
  2. fully reversible sensory symptoms including positive features (e.g., pins and needles) and/or negative features (e.g., numbness)
  3. fully reversible dysphasic speech disturbance

C.

At least two of the following:

  1. homonymous visual symptoms and/or unilateral sensory symptoms
  2. at least one aura symptom develops gradually over ≥5 minutes and/or different aura symptoms occur in succession over ≥5 minutes
  3. each symptom lasts ≥5 and ≤60 minutes

D.

Headache fulfilling criteria B–D for migraine without aura begins during the aura or follows aura within 60 minutes

E.

Not attributable to another disorder

Pure menstrual migraine without aura

A.

Attacks, in a menstruating woman, fulfilling criteria for migraine without aura

B.

Attacks occur exclusively on Day 1 ±2 days (i.e., Days +2 to –3) of menstruation in at least two out of three menstrual cycles and at no other times of the cycle

Estrogen-withdrawal headache

A.

Headache or migraine fulfilling criteria C and D

B.

Daily use of exogenous estrogen for >3 weeks, which is interrupted

C.

Headache or migraine develops within 5 days after last use of estrogen

D.

Headache or migraine resolves within 3 days

Exogenous hormone-induced headache

A.

Headache or migraine fulfilling criteria C and D

B.

Regular use of exogenous hormones

C.

Headache or migraine develops or markedly worsens within 3 months of commencing exogenous hormones

D.

Headache or migraine resolves or reverts to its previous pattern within 3 months after total discontinuation of exogenous hormones

Source: International Headache Society1

 

CASE 1: Patient reports a history of migraine

A 21-year-old nulliparous woman has severe dysmenorrhea that has been unresponsive to treatment with nonsteroidal anti-inflammatory drugs (NSAIDs). She also desires contraception. Her primary care provider has recommended combination oral contraceptives (OCs) as a solution to both problems. However, the patient has heard from friends that she should not use OCs because of her history of migraine headache, and she has come to see you for a second opinion.

She describes her headaches as bilateral and reports a “tightening” sensation. The headaches are associated with photophobia and are not aggravated by routine physical activity. They respond to NSAIDs.

She also reports that her mother and sister have been on a prescription medication for migraines for many years.

Is an OC appropriate for this patient?

This young woman’s history is consistent with tension-type headache, not migraine. Tension headache is the most common subtype, with prevalence as high as 59% in women of reproductive age.2 It is generally characterized by mild or moderate pain that is bilateral, pressing, or tightening in quality. The pain does not worsen with routine physical activity. There is no nausea, but photophobia or phonophobia may be present.1

A systematic review of the risk of stroke associated with combination OC use and headaches did not find any studies examining the association between nonmigraine headache and the risk of stroke among combination OC users.3 In contrast to some migraines, however, tension-type headache has not been associated with an increased risk of stroke in the general population. Nor is there evidence that hormonal fluctuations play a role in the pathogenesis or clinical course of tension headache.

In summary, there are no contraindications to combination hormonal contraceptives—including estrogen-progestin OCs, the contraceptive patch, and the contraceptive ring—in women who have tension headache.4

Explore any family history of migraine

The patient in Case 1 appears to have a family history of migraine. Some evidence suggests that such a family history increases the risk of new-onset migraine with use of a combination OC.5 Because the background prevalence of migraine is so high in the population of women likely to use a combination OC, it can be difficult to determine whether worsening headache or development of migraine with OC use is causal or coincidental.

Were this patient to express concern over even a theoretical risk of triggering migraine headache, then a combination OC would probably not be appropriate. In the absence of such concern, however, there is no reason to withhold hormonal contraception. Progestin-only options exist that will provide her with excellent contraceptive efficacy and help relieve her dysmenorrhea:

  • the etonogestrel subdermal implant (Implanon)
  • depot medroxyprogesterone acetate (DMPA) injection (Depo-Provera)
  • the levonorgestrel-releasing intrauterine system (LNG-IUS; Mirena).

Although some women do develop headaches while using progestin-only contraceptives, there is no evidence that such use can trigger a new migraine syndrome in a woman with a family history of such. Again, however, the data are limited.

Progestin methods are safe

The use of progestin-only methods has been promoted in headache sufferers, especially those who have a specific diagnosis of migraine, because progestins do not add to the elevated risk of stroke that accompanies migraine with aura.

Because headache is common in women of reproductive age, it is not surprising that it is listed as a common adverse event for all contraceptives, including progestin-only methods. Evidence that progestin-only methods cause or worsen headaches is slim, however. Preliminary studies indicate that mid-luteal elevations of progesterone or its metabolites could prevent migraine, compared with other times in the cycle.6 Older studies report that a daily oral progestin could prevent migraine in premenopausal women, possibly secondary to induction of anovulation. At the same time, there are clinical reports that DMPA may trigger headache as a side effect in susceptible women.

Generally, then, although progestin-only methods are likely to be safe in all patients with headache, and ovulation suppression may improve the headaches, some patients may experience worsening symptoms.

CASE 2: OC user reports migraine with aura

A 26-year-old mother of one comes to your office for her annual exam. She has used combination OCs for 2 years. She also has a history of severe headaches, which occur four or five times a year. She says the headaches are unilateral, pulsating, and associated with photophobia. The symptoms worsen when she is active and are preceded by a flashing zigzag line that migrates from the center of her visual field to the lateral periphery. The headaches are not associated with her menstrual cycle and have not changed in character or frequency since she began using an OC. She does not smoke.

Should she continue taking an OC?

This patient’s history is consistent with migraine headache with aura. Migraine is a common, disabling primary headache disorder, with an estimated 1-year prevalence in adult women of 15% to 18% and a lifetime prevalence of about 30%.2 Approximately 10% to 20% of people who have migraine experience auras.7

Research on the association between combination OCs, migraine, and stroke has been limited by the rarity of the outcome in the population of concern. Most data come from case-controlled studies and are fettered by a lack of standardized criteria for the diagnosis of migraine (few studies use criteria from the IHS); by recall bias (such as self-reported OC use); and by survivorship bias. Many studies fail to differentiate by the presence of aura, which indicates a different effect on cerebral blood flow patterns than does migraine without aura.

Although most studies attempt to control for the confounding effect of smoking, some do not, and in others the prevalence of smoking is so high it can be difficult to remove from the equation. Some of the studies examining the association between migraine and stroke do not differentiate by gender.

Taking all these variables into account, migraine in women independently appears to carry a twofold to threefold increased risk of ischemic stroke, compared with the risk in similarly aged women who do not have migraine.8 Among women who have a history of migraine, those who use combination OCs are two times to four times more likely to experience ischemic stroke than nonusers are. Among women with the highest risk (combination OC users with migraine), the odds ratio for ischemic stroke ranges from 6 to almost 14, compared with women with the lowest risk (nonusers without migraine).3

To put all this in perspective, the absolute risk of stroke for a 26-year-old nonsmoker like our patient is 6 cases in every 100,000 woman-years.9 Multiplying this risk by a factor of 3 to account for her migraines, and by 3 again to account for her OC use, we can roughly estimate her absolute risk of stroke as about 54 cases for every 100,000 woman-years. Although this absolute risk is extremely low, the outcome can be catastrophic. It behooves us to proceed with caution.

What is a migraine aura?

Continued...
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