Clinical Review

How to choose a contraceptive for a patient who has headaches

OBG Manag. 2011 February;23(2):20-28

References

1. International Headache Society. The international classification of headache disorders: 2nd edition. Cephalalgia. 2004;24(suppl 1):9-160.

2. Rasmussen BK. Epidemiology of headache. Cephalalgia. 2001;21(7):774-777.

3. Curtis KM, Mohllajee AP, Peterson HB. Use of combined oral contraceptives among women with migraine and nonmigrainous headaches: a systematic review. Contraception. 2006;73(2):189-194.

4. Harris M, Kaneshiro B. An evidence-based approach to hormonal contraception and headaches. Contraception. 2009;80(5):417-421.

5. Loder EW, Buse DC, Golub JR. Headache and combination estrogen-progestin oral contraceptives: integrating evidence, guidelines, and clinical practice. Headache. 2005;45(3):224.

6. Martin VT, Behbehani M. Ovarian hormones and migraine headache: understanding mechanisms and pathogenesis— part 2. Headache. 2006;46(3):365-386.

7. Macgregor EA. Menstrual migraine: a clinical review. J Fam Plann Reprod Health Care. 2007;33(1):36-47.

8. Etminan M, Takkouche B, Isorna FC, et al. Risk of ischaemic stroke in people with migraine: systematic review and metaanalysis of observational studies. BMJ. 2005;330(7482):63.-

9. Petitti DB, Sidney S, Quesenberry CP, Jr. Bernstein A. Incidence of stroke and myocardial infarction in women of reproductive age. Stroke. 1997;28(2):280-283.

10. Carolei A, Marini C, De Matteis G. History of migraine and risk of cerebral ischaemia in young adults. Lancet. 1996;347(9014):1503-1506.

11. Chang CL, Donaghy M, Poulter N. Migraine and stroke in young women: case-control study. BMJ. 1999;318(7175):13.

12. Kurth T, Slomke MA, Kase CS, et al. Migraine, headache, and the risk of stroke in women: a prospective study. Neurology. 2005;64(6):1020-1026.

13. MacClellan LR, Giles W, Cole J, et al. Probable migraine with visual aura and risk of ischemic stroke: the stroke prevention in young women study. Stroke. 2007;38(9):2438-2445.

14. Tzourio C, Kittner SJ, Bousser MG, Alperovitch A. Migraine and stroke in young women. Cephalalgia. 2000;20(3):190-199.

15. Tzourio C, Tehindrazanarivelo A, Iglesias S, et al. Case-control study of migraine and risk of ischaemic stroke in young women. BMJ. 1995;310(6983):830-833.

16. ACOG practice bulletin. No. 73: Use of hormonal contraception in women with coexisting medical conditions. Obstet Gynecol. 2006;107(6):1453-1472.

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18. Bousser MG, Conard J, Kittner S, et al. Recommendations on the risk of ischaemic stroke associated with use of combined oral contraceptives and hormone replacement therapy in women with migraine. The International Headache Society Task Force on Combined Oral Contraceptives & Hormone Replacement Therapy. Cephalalgia. 2000;20(3):155-156.

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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?

A common misperception among health-care providers is that nausea, vomiting, photophobia, and phonophobia represent migraine aura, when in fact these symptoms are part of the associated diagnostic symptoms of all migraines.

About 20% of people who have migraine experience an aura. The aura begins before the headache and typically lasts 5 to 20 minutes—rarely does it last more than 60 minutes. The headache occurs soon after the aura stops.

The aura may include zigzag lines of light, flashing lights or bright spots, blurred or darkened spots, or focal neurologic symptoms such as numbness or tingling in the fingers of one hand, lips, tongue, or lower face. Auras may involve other senses, such as smell, and can occasionally cause temporary focal weakness or changes in speech.

Presence of aura likely confers greater risk

Many studies of migraine do not explore contraceptive use. They report a higher risk of stroke when aura is present.^8,10-15 One of the few prospective studies found no increased risk of stroke in migraineurs who did not experience aura.¹²

No studies examining a link between combination OCs and ischemic stroke in migraineurs have been large enough to stratify the risk of stroke by the presence or absence of aura. The assumption has been that this risk is amplified by use of combination OCs. Consequently, migraine with aura is designated as an absolute contraindication to the use of combination OCs by the World Health Organization (WHO), ACOG, and the IHS.^4,16Although no studies have included women using the contraceptive patch or ring, it is assumed that these methods carry a risk of ischemic stroke similar to that of combination OCs.¹⁷ The IHS recommendations on combination hormonal contraception in women with migraine are given in TABLE 2.¹⁸

TABLE 2

When combination OCs are appropriate for a woman who has migraine

There is no contraindication to the use of combination OCs in a woman who has migraine in the absence of migraine aura or other risk factors Counsel and regularly assess the patient for the development of additional risk factors for ischemic stroke Additional risk factors for ischemic stroke in a woman who has migraine and who uses a combination OC: – age >35 years – ischemic heart disease or cardiac disease with embolic potential – diabetes mellitus – family history of arterial disease at <45 years of age – hyperlipidemia – hypertension – migraine aura – obesity (body mass index >30) – smoking – systemic diseases associated with stroke, including sickle cell disease and connective tissue disorders The risk of ischemic stroke may be increased in women who have migraine and who are using a combination OC when additional risk factors are present that cannot be controlled, including migraine with aura Physicians should: – identify and evaluate risk factors for ischemic stroke – determine the type of migraine – advise the patient to stop smoking before prescribing combination OCs – treat other risk factors, such as hypertension and hyperlipidemia – consider contraceptive methods that do not contain estrogen
Source: International Headache Society¹⁸

There is no contraindication to the use of combination OCs in a woman who has migraine in the absence of migraine aura or other risk factors
Counsel and regularly assess the patient for the development of additional risk factors for ischemic stroke
Additional risk factors for ischemic stroke in a woman who has migraine and who uses a combination OC:
- – age >35 years
  – ischemic heart disease or cardiac disease with embolic potential
  – diabetes mellitus
  – family history of arterial disease at <45 years of age
  – hyperlipidemia
  – hypertension
  – migraine aura
  – obesity (body mass index >30)
  – smoking
  – systemic diseases associated with stroke, including sickle cell disease and connective tissue disorders

The risk of ischemic stroke may be increased in women who have migraine and who are using a combination OC when additional risk factors are present that cannot be controlled, including migraine with aura
Physicians should:
- – identify and evaluate risk factors for ischemic stroke
  – determine the type of migraine
  – advise the patient to stop smoking before prescribing combination OCs
  – treat other risk factors, such as hypertension and hyperlipidemia
  – consider contraceptive methods that do not contain estrogen

Source: International Headache Society¹⁸