23rd November 2010
Taking the Headache out of Contraception and HRT
Taking the Headache out of Contraception & HRT
Anne MacGregor www.migraineclinic.org.uk
[email protected]
Do you have the following with your headaches? • You feel nauseated or sick? • Light bothers you more than usual? • Your headaches limit your ability to work, study or do what you need to do for at least one day?
Lipton et al. Neurology 2003;61:375-82
Anne MacGregor
23rd November 2010
Taking the Headache out of Contraception and HRT
Do you have the following with your headaches? • You feel nauseated or sick? • Light bothers you more than usual? • Your headaches limit your ability to work, study or do what you need to do for at least one day? Positive predictive value for migraine diagnosis: 2 positive answers – PPV = 93% 3 positive answers - PPV = 98%
Lipton et al. Neurology 2003;61:375-82
Migraine ‘Threshold’
Genetic Predisposition/ Prophylaxis
threshold HORMONAL TRIGGER LACK OF FOOD DEHYDRATION MUSCULAR PAIN LACK OF SLEEP
MacGregor EA. Cephalalgia 1996;16:111996;16:11-21
Anne MacGregor
23rd November 2010
Taking the Headache out of Contraception and HRT
Migraine Migraine without aura
• 70-80% attacks
Migraine with aura
• 20-30% attacks • 1% without headache
Combined hormonal contraception •Synthetic estrogen and progestogen •Doses to inhibit ovulation
Anne MacGregor
Taking the Headache out of Contraception and HRT
Questions • Suitability of CHCs/HRT in women with migraine – Type of migraine – Risks of CHCs/HRT in women with migraine – When it occurs: • CHCs: during hormones; hormone-free interval; • HRT: estrogen-only phase; estrogen/progestogen phase; period
• Drug interactions • Alternatives
Case History 1 • • • • • • •
Anne MacGregor
37-year old woman Migraine since teens Took CHCs for 8 years in the past Stopped CHCs to become pregnant CHCs for last 5 years after birth of 2nd child Migraine without aura in the pill-free week Should she continue CHCs?
23rd November 2010
23rd November 2010
Taking the Headache out of Contraception and HRT
Course of migraine with COCs
*3 cases of aura occurred for first time with COC Machado RB et al. Contraception 2010 81:202–8
Migraine in hormone-free interval (HFI) of CHCs 50 cycles
Day of hormone free interval MacGregor EA. Menstrual migraine: the role of oestrogen. London, 2008
Anne MacGregor
23rd November 2010
Taking the Headache out of Contraception and HRT
Migraine during HFI • Estrogen ‘withdrawal’ • Typically migraine without aura
Prevention • Period-free regimen – Long-cycle/continuous CHC
Sulak PJ et al Am J Obstet Gynecol 2002;186:1142-9 LaGuardia KD et al Fertil Steril 2005;83:1875-7
Anne MacGregor
23rd November 2010
Taking the Headache out of Contraception and HRT
Mean headache days by week with EVRA® extended vs cyclic regimen
LaGuardia KD et al Fertil Steril 2005;83:1875-7
Mean daily headache score: extended versus cyclic CHCs (0-10) Average Daily Headache Score (0
2.0
Means and SE for 102 patients 1.5
21/7 days DRSP/EE versus 168 days DRSP/EE
1.0
0.5
0.0 21/7
21/7
168168-day extended regimen
SE = standard error; DRSP = drospirenone; EE = ethinyl estradiol
.Adapted from Sulak P et al. Headache 2007;47:27-37.
Anne MacGregor
Taking the Headache out of Contraception and HRT
Prevention • If women wishes to have ‘periods’
MacGregor EA, Hackshaw A J Fam Plann Reprod Healthcare 2002; 28:27-31 Calhoun A & Ford S. Headache 2008;48:1186-1193
Prevention • If women wishes to have ‘periods’ – Natural estrogen supplements during HFI • 100mcg patch on last day of pill packet • Replace on 4th day of hormone-free interval • Remove on 1st day of next packet
– Shortened HFI
MacGregor EA, Hackshaw A J Fam Plann Reprod Healthcare 2002; 28:27-31 Calhoun A & Ford S. Headache 2008;48:1186-1193
Anne MacGregor
23rd November 2010
Taking the Headache out of Contraception and HRT
Case History 2 • • • •
32-year old woman Migraine since age 22 On CHCs for last 8 years She says that she gets ‘spots in front of her eyes’ before her migraines • Should she continue with CHCs?
Is it aura?
Anne MacGregor
23rd November 2010
23rd November 2010
Taking the Headache out of Contraception and HRT
When does a migraine start? headache
vomiting
anorexia/nausea/vomiting
sleep
malaise/ lethargy
food craving tired/yawning
drugs
sensitive to light/sound heightened sense of smell
heightened perception
limited food tolerance tired hungover
difficulty focusing
diuresis
poor concentration fluid retention
normal
I premonitory
2-24 hrs
II aura
III headache
