Clinical Review

How to choose a contraceptive for a patient who has headaches

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Developing an accurate diagnosis of headache subtype will help avert unnecessary restriction of hormonal methods among your patients who do not have “pure” migraine




Headaches are highly prevalent in women during their reproductive years. Most are a painful nuisance and do not present a risk of serious morbidity. Some, however, can be dangerous, and the addition of an estrogen-containing contraceptive can increase that risk.

Combination estrogen-progestin contraceptives are effective, popular, and easy to use—but are they safe for women who have headaches? This is a critical question. Some women who have preexisting headaches experience relief with hormonal contraception; others report stable or worsening symptoms; still others do not develop headaches until they begin hormonal contraception.

The differentiation between nuisance and true medical risk in this population depends on an accurate diagnosis of headache subtype. Taking a few moments to confirm whether a patient with headache has a true risk if she chooses hormonal contraception will prevent unnecessary restriction of a method and promote contraceptive success.

In this article, we present three cases that facilitate discussion of the safety, adverse effects, and benefits of various contraceptive strategies in women who have headaches.

Many women who report migraines don’t have them

Most women who report headaches to their gynecologist have not received a clinical diagnosis of headache subtype. They may say that they have “migraines” because that is the term used most commonly in the United States to indicate a severe level of distress with a headache. In actuality, although migraine is common in women, tension-type headaches are more prevalent.

The evaluation of a patient with headaches who is seeking contraception should begin with a simple diagnostic algorithm for headache type. Accurate diagnosis can be made using the International Headache Society (IHS) comprehensive guide for headache subtypes, last updated in 2004.1TABLE 1, presents a simple classification of chronic headache syndromes, which account for more than 90% of headaches.


Diagnostic criteria for headache subtypes

Infrequent episodic
A.At least 10 episodes <1 day per month on average (<12 days per year) and fulfilling criteria B–D below
Frequent episodic
A.At least 10 episodes occurring ≥1 but <15 days per month for at least 3 months (≥12 and <180 days per year) and fulfilling criteria B–D
B.Headache lasting for 30 minutes to 7 days
C.Headache has at least two of the following characteristics:
  1. bilateral location
  2. pressing/tightening (nonpulsating) quality
  3. mild or moderate intensity
  4. not aggravated by routine physical activity such as walking or climbing stairs
D.Both of the following:
  1. no nausea or vomiting (anorexia may occur)
  2. no more than one of photophobia or phonophobia
E.Not attributable to another disorder
A.At least 5 attacks fulfilling criteria B–D
B.Severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting 15–180 minutes if untreated
C.Headache is accompanied by at least one of the following:
  1. ipsilateral conjunctival injection and/or lacrimation
  2. ipsilateral nasal congestion and/or rhinorrhea
  3. ipsilateral eyelid edema
  4. ipsilateral forehead and facial sweating
  5. ipsilateral miosis and/or ptosis
  6. a sense of restlessness or agitation
D.Attacks have a frequency from one every other day to 8 per day
E.Not attributable to another disorder
Migraine without aura
At least 5 attacks fulfilling criteria B–D
A.Headache attacks lasting 4–72 hours (untreated or successfully treated)
B.Headache has at least two of the following characteristics:
  1. unilateral location
  2. pulsating quality
  3. moderate or severe pain intensity
  4. aggravation by or causing avoidance of routine physical activity (e.g., walking or climbing stairs)
C.During headache at least one of the following:
  1. nausea and/or vomiting
  2. photophobia and phonophobia
D.Not attributable to another disorder
Typical migraine with aura headache
A.At least 2 attacks fulfilling criteria B–D
B.Aura consisting of at least one of the following, but no motor weakness:
  1. fully reversible visual symptoms including positive features (e.g., flickering lights, spots, or lines) and/or negative features (e.g., loss of vision)
  2. fully reversible sensory symptoms including positive features (e.g., pins and needles) and/or negative features (e.g., numbness)
  3. fully reversible dysphasic speech disturbance
C.At least two of the following:
  1. homonymous visual symptoms and/or unilateral sensory symptoms
  2. at least one aura symptom develops gradually over ≥5 minutes and/or different aura symptoms occur in succession over ≥5 minutes
  3. each symptom lasts ≥5 and ≤60 minutes
D.Headache fulfilling criteria B–D for migraine without aura begins during the aura or follows aura within 60 minutes
E.Not attributable to another disorder
Pure menstrual migraine without aura
A.Attacks, in a menstruating woman, fulfilling criteria for migraine without aura
B.Attacks occur exclusively on Day 1 ±2 days (i.e., Days +2 to –3) of menstruation in at least two out of three menstrual cycles and at no other times of the cycle
Estrogen-withdrawal headache
A.Headache or migraine fulfilling criteria C and D
B.Daily use of exogenous estrogen for >3 weeks, which is interrupted
C.Headache or migraine develops within 5 days after last use of estrogen
D.Headache or migraine resolves within 3 days
Exogenous hormone-induced headache
A.Headache or migraine fulfilling criteria C and D
B.Regular use of exogenous hormones
C.Headache or migraine develops or markedly worsens within 3 months of commencing exogenous hormones
D.Headache or migraine resolves or reverts to its previous pattern within 3 months after total discontinuation of exogenous hormones
Source: International Headache Society1


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