CME

Combined hormonal contraceptives and migraine: An update on the evidence

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Release date: August 1, 2017
Expiration date: July 31, 2018
Estimated time of completion: 1 hour

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ABSTRACT

Combined hormonal contraceptives are contraindicated in women who have migraine with aura, in whom these drugs can increase the risk of ischemic stroke. However, this contraindication is based on data from the 1960s and 1970s, when oral contraceptives contained much higher doses of estrogen. Stroke risk is not significantly increased with today’s preparations, many of which contain less than 30 μg of ethinyl estradiol. Further, in continuous regimens, ultra-low-dose formulations—those that contain less than 20 µg of ethinyl estradiol—may help prevent menstrual migraine and reduce the frequency of aura.

KEY POINTS

  • There is no restriction on the use of combined hormonal contraceptives by women with migraine without aura, and the risk vs benefit for women with aura is debatable.
  • Migraine with aura—but not migraine without aura—is associated with a twofold increased risk of ischemic stroke, although the absolute risk is small in healthy women who do not smoke.
  • Combined hormonal contraceptives are associated with ischemic stroke, but the risk is dose-dependent. Ultra-low-dose formulations (containing ≤ 20 μg of ethinyl estradiol) do not pose an increased risk of stroke in healthy nonsmokers.

 

References

Combined hormonal contraceptives are contraindicated in women who have migraine with aura because they pose a risk of stroke. But how great is the risk, and how strong is the evidence, particularly with today’s low-dose contraceptives? Can we view migraine with aura as a relative contraindication rather than an absolute one?

This article reviews migraine diagnosis, the effects of estrogen and the menstrual cycle on migraine, the evidence of stroke risk with combined hormonal contraceptive use, and how the frequency of aura may affect risk. It offers practical advice on choosing contraceptive formulations and counseling patients on risks and benefits.

WHAT THE GUIDELINES SAY

Current guidelines restrict the use of combined hormonal contraceptives in the setting of migraine with aura, but not in migraine without aura.

A practice bulletin from the American College of Obstetrics and Gynecology in 2010 noted that extended-cycle or continuous hormonal contraceptives, including oral and parenteral products, might provide relief of migraines by eliminating the drops in estrogen levels that precipitate them.1 However, the bulletin also cautioned that though cerebrovascular accidents in women are rare, the impact of a stroke is so devastating that clinicians should consider intrauterine devices, progestin-only options, and other nonestrogen methods in women who have migraine with focal neurologic signs, women who smoke, and women age 35 or older.1

In 2016, the US Centers for Disease Control and Prevention published updates to its medical eligibility criteria for contraceptive use in various medical conditions. In the case of migraine without aura, the guidelines note no limitation to the use of combined hormonal contraceptives, regardless of the patient’s age. In the case of migraine with aura, the consensus was that the risk associated with combined hormonal contraception typically outweighs its benefits, noting “an unacceptable health risk if the contraceptive method is used.”2

We believe a fresh look at the data is warranted.

EARLY ORAL CONTRACEPTIVES WERE ALL HIGH-DOSE

This issue first surfaced in the decade and a half after the initial launch of oral contraceptives in 1960. The products then were all high-dose pills, containing up to 150 µg of mes­tranol. In subsequent decades, the dose of estrogen was successively reduced, so that now some pills contain only 10 µg of ethinyl estradiol. High-dose pills—which today contain 50 µg of ethinyl estradiol—account for less than 1% of pills currently sold in the United States and have been eliminated in many countries.

DIAGNOSTIC CRITERIA FOR MIGRAINE

According to the International Classification of Headache Disorders (ICHD),3 the diagnosis of migraine requires 2 of the 4 following criteria:

  • Unilateral location
  • Pulsating or throbbing pain
  • Pain of at least moderate intensity
  • Pain aggravated by activity, or causing a preference to avoid activity.

An additional criterion is either nausea or a combination of photophobia and phonophobia with the episode. This criterion can be met if the patient prefers to avoid bright lights and loud noises during an attack.

Headache experts have suggested that patients with a stable pattern of episodic, disabling headache and normal findings on physical examination should be considered to have migraine if there is no contradictory evidence.4,5

Migraine with aura requires at least 2 of the following 4 characteristics3:

  • 1 aura symptom, spreading gradually over 5 minutes, or 2 or more aura symptoms occurring in succession, or both
  • Each aura symptom lasting 5 to 60 minutes (not “a few seconds,” not “hours”)
  • The aura followed by the onset of headache within 60 minutes
  • At least 1 aura symptom is unilateral.

Visual blurring, floaters, or split-second flashes before or during a migraine headache do not meet the criteria for aura.

MIGRAINE IS COMMON AND UNDERRECOGNIZED

In a study of 1,203 patients seeking care from a primary care provider for headache,6 94% of the 377 who turned in a diary with enough data to make a diagnosis were diagnosed with a migraine or probable migraine by an expert panel. A quarter of patients who likely had migraine based on an expert review of symptoms did not receive a migraine diagnosis at the time of their office visit.

Similarly, in a large epidemiologic study,7 30,758 adults were asked if they had headaches and, if so, how they named them. Headaches were reported by 23,564 of the participants and were subsequently diagnosed by formal ICHD criteria. Of the 3,074 individuals who met the criteria for migraine, only 53.4% correctly recognized their headaches as migraine. The most common erroneous labels were “sinus headache” and “stress headache.”7

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