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.