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Headache and Combination Estrogen-Progestin Oral
Contraceptives: Integrating Evidence, Guidelines, and
Clinical Practice
Elizabeth Loder, Dawn Buse, Joan Golub
Posted: May 2005
Headache 2005;45:224-231
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Primary headache disorders such as migraine affect
almost a third of women during their childbearing years, when
decisions about contraception must be made. Headache is also a
commonly reported adverse event in clinical trials of oral
contraceptives (OCs). Health care practitioners will frequently
be called upon to give advice about the use of OCs to women with
headache. This article applies current evidence, guidelines, and
recommendations about headache and OC use to treatment decisions
in four clinical scenarios: initiating OC use in a woman who has
migraine without aura, continuing OC use in a woman who experiences
worsening of migraine and the development of aura after initiating
OCs, initiating OC use in a woman with tension-type headache (TTH)
and a family history of migraine, and use of an extended duration
OC regimen to minimize migraine triggered by estrogen withdrawal.
Case 1: A 23-year old woman has severe dysmenorrhea
that has been unresponsive to treatment with NSAIDs. She has
migraine without aura and takes sodium valproate 250 mg. twice
daily for migraine prevention. Because she desires contraception,
OCs have been recommended as treatment of dysmenorrhea. The patient
has heard through friends and the popular press that because she
has migraine she should not use OCs. Her neurologic examination is
normal and she has no other contraindications to OC use.
Recommendations: This patient has migraine without
aura, is under 35, has no additional risk factors for stroke, and
is likely to experience important improvement in another condition
from OC use. Avoidance of unintended pregnancy is especially
important in this patient because she is taking valproate, a known
teratogen. For her, the benefits of OC use probably outweigh the
drawbacks, and this assessment is supported by professional
guidelines.
Case 2: A 38-year old woman consults a new physician
6 months after beginning OC use. Shortly after starting OCs, she
began to experience headaches twice a week lasting 12 to 16 hours.
The headaches are bilateral, throbbing, and accompanied by nausea
and sensitivity to light and sound. They are preceded by a 45-minute
visual disturbance consisting of a "bright, shimmering, zigzag line"
that enlarges, moves to the periphery of her visual field and then
fades away as the headache begins. Upon questioning, she reports
occasional similar headaches prior to OC use that were "not as bad".
The visual disturbance associated with the headache is new. Her
neurologic examination is normal. The patient smokes 1 pack per
day of cigarettes. Recommendations: This patient has
a history of occasional migraine without aura that was not
recognized prior to beginning OC use. Migraine without aura by
itself is not a contraindication to OC use, but this patient has
additional stroke risk factors of age and smoking. Coincident with
OC use, her headaches have increased in frequency and are now
associated with neurologic accompaniments that meet diagnostic
criteria for aura. In general, a worsening of headaches, either in
severity or frequency, or the new onset of headaches or neurologic
accompaniments to headache requires further evaluation. For this
patient, it would be prudent to use other forms of birth control.
Case 3: A 20-year old woman would like to begin OC
use, but has an older sister whose severe migraine headaches began
when she started OC use. A maternal grandmother had frequent "sick
headaches." The patient reports a personal history of mild headaches
occurring 6 to 8 times yearly for the past 4 years. These last 3 to
4 hours and are bilateral, pressing, or tightening in quality, and
not associated with nausea, vomiting, photophobia or phonophobia.
The headaches respond well to over-the-counter medications such as
NSAIDs. Her neurologic examination is normal and there are no other
contraindications to OC use. Recommendations: The
decision about OC use in this case must be made by the patient and
her health care provider. It involves weighing the potential
benefits of OC use and the strength of other reasons for OC use
against the small but real risk of headache precipitation. The
patient may have compelling reasons for OC use that she judges
outweigh the risk of headache. Conversely, if her sister has
severe, disabling headaches that have been unresponsive to
treatment, the prospect of developing headache might be
unacceptable to her.
Case 4: A 33 year old woman has used COCs (combination
oral contraceptives) since college and is generally satisfied with
them. She has an average of 13 episodes of migraine without aura
yearly that occur almost exclusively during the pill-free week of
her OC regiment. She seeks advice about reports in the popular
press suggesting that extended duration OC use may decrease
estrogen-withdrawal symptoms such as headache. She has no other
contraindications to OC use and her neurologic exam is normal.
Recommendations: Hormonal manipulation is not the first-line
treatment for estrogen-withdrawal headaches. However, this patient
is already using OCs for contraceptive purposes and would like to
have fewer episodes of withdrawal bleeding. She has no other
contraindications to OC use. With the exception of headache during
the placebo week, she has tolerated OCs well for more than a decade.
Thus, a trial of extended duration OC use, in an attempt to minimize
headache, is reasonable. This patient should be counseled about the
unknown, but probably small, risks associated with a slight overall
increase in hormonal exposure with this method. Additionally, she
should be closely monitored in order to ascertain any headache
changes on this treatment.
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