Combined hormonal contraception and migraine: are we being too strict?

Voedisch, Amy; Hindiyeh, Nada

doi:10.1097/gco.0000000000000586

Cited by 6 publications

(4 citation statements)

References 45 publications

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“…Lastly, it is important to acknowledge that differences exist between guidelines used by neurologists and gynecologists, with the former generally taking a more liberal approach [13]. In 2000, a Task Force by the International Headache Society (IHS) provided official recommendations regarding the use of COCs and hormone replacement therapy in patients with migraines.…”

Section: Discussionmentioning

confidence: 99%

“…Withdrawal from estrogen also contributes to migraine susceptibility by decreasing serotonergic tone and affecting central opioid tonus [11]. One study found that the rate of decline in estrogen levels following the luteal peak was significantly greater in patients with migraine compared to those without migraines [13]. By contrast, higher concentrations of estrogen have been associated with higher aura frequencies in patients who get migraines with aura [14].…”

Section: Migraine Background and Physiologymentioning

confidence: 99%

“…Other studies that showed the increased risk of stroke in CHC users rarely stratified risk by hormone dosing, and as the hormone levels in CHCs were reduced with new formulations over the years, decreases in adverse events have been consistently observed across numerous studies [13]. One pooled US study reviewed 3.6 million woman-years and found no increased stroke risk in users of low-dose COCs.…”

Section: Chc Use and Ischemic Stroke Riskmentioning

confidence: 99%

“…Although studies of this magnitude are helpful in gaining confidence in clinical recommendations, there are still many limitations. Given the timeline of this study, the study population using CHCs were exposed to modern dosing of estrogens, though in previous studies and older reviews, the same assumption cannot be made as easily [10,13,14].…”

Section: Chc Use In Migraine Patientsmentioning

confidence: 99%

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Considerations for Contraceptive Use Among Patients with Migraines

Lyall

Oliveira

Mody

2023

Curr Obstet Gynecol Rep

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Purpose of Review There is an overlap in the populations of patients who suffer from migraine headaches and patients who seek contraception. The purpose of this review is to present recent studies on contraception among patients with migraines and provide clinical recommendations. Recent Findings Migraine with aura and combined hormonal contraceptive (CHC) use are associated with increased ischemic stroke risk. The use of CHCs in patients with migraine with aura produces a higher risk of ischemic stroke than either factor individually; therefore, CHC is contraindicated in this population by certain guidelines. However, recent studies suggest that oral contraceptive may reduce migraine days, pain scores, and migraine medication use. Summary Certain guidelines recommend against use of CHCs in patients with migraine with aura. CHC use is acceptable among patient with migraines without aura. In patients with menstrual-related migraines, there may be benefit from continuous use of oral contraceptives. Further studies are needed on migraine and specific formulations of CHC, if the frequency of migraines with aura impacts ischemic stroke risk and the impact of oral and non-oral contraceptives on menstrual headaches.

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Section: Discussionmentioning

confidence: 99%

Section: Migraine Background and Physiologymentioning

confidence: 99%

Section: Chc Use and Ischemic Stroke Riskmentioning

confidence: 99%

Section: Chc Use In Migraine Patientsmentioning

confidence: 99%

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Considerations for Contraceptive Use Among Patients with Migraines

Lyall

Oliveira

Mody

2023

Curr Obstet Gynecol Rep

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Sex and Gender Considerations in Episodic Migraine

Ahmad

Rosendale

2022

Curr Pain Headache Rep

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Purpose of Review We seek to update readers on recent advances in our understanding of sex and gender in episodic migraine with a two part series. In part 1, we examine migraine epidemiology in the context of sex and gender, differences in symptomatology, and the influence of sex hormones on migraine pathophysiology (including CGRP). In part 2, we focus on practical clinical considerations for sex and gender in episodic migraine by addressing menstrual migraine and the controversial topic of hormone-containing therapies. We make note of data applicable to gender minority populations, when available, and summarize knowledge on gender affirming hormone therapy and migraine management in transgender individuals. Finally, we briefly address health disparities, socioeconomic considerations, and research bias. Recent Findings Migraine is known to be more prevalent, frequent, and disabling in women. There are also differences in migraine co-morbidities and symptomatology. For instance, women are likely to experience more migraine associated symptoms such as nausea, photophobia, and phonophobia. Migraine pathophysiology is influenced by sex hormones, e.g., estrogen withdrawal as a known trigger for migraine. Other hormones such as progesterone and testosterone are less well studied. Relationships between CGRP (the target of new acute and preventive migraine treatments) and sex hormones have been established with both animal and human model studies. The natural course of migraine throughout the lifetime suggests a contribution from hormonal changes, from puberty to pregnancy to menopause/post-menopause. Treatment of menstrual migraine and the use of hormone-containing therapies remains controversial. Re-evaluation of the data reveals that stroke risk is an estrogen dose- and aura frequency-dependent phenomenon. There are limited data on episodic migraine in gender minorities. Gender affirming hormone therapy may be associated with a change in migraine and unique risks (including ischemic stroke with high dose estrogen). Summary There are key differences in migraine epidemiology and symptomatology, thought to be driven at least in part by sex hormones which influence migraine pathophysiology and the natural course of migraine throughout the lifetime. More effective and specific treatments for menstrual migraine are needed. A careful examination of the data on estrogen and stroke risk suggests a nuanced approach to the issue of estrogen-containing contraception and hormone replacement therapy is warranted. Our understanding of sex and gender is evolving, with limited but growing research on the relationship between gender affirming therapy and migraine, and treatment considerations for transgender people with migraine.

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