Effect of exogenous estrogens and progestogens on the course of migraine during reproductive age: a consensus statement by the European Headache Federation (EHF) and the European Society of Contraception and Reproductive Health (ESCRH)

Abstract

We systematically reviewed data about the effect of exogenous estrogens and progestogens on the course of migraine during reproductive age. Thereafter a consensus procedure among international experts was undertaken to develop statements to support clinical decision making, in terms of possible effects on migraine course of exogenous estrogens and progestogens and on possible treatment of headache associated with the use or with the withdrawal of hormones. Overall, quality of current evidence is low. Recommendations are provided for all the compounds with available evidence including the conventional 21/7 combined hormonal contraception, the desogestrel only oral pill, combined oral contraceptives with shortened pill-free interval, combined oral contraceptives with estradiol supplementation during the pill-free interval, extended regimen of combined hormonal contraceptive with pill or patch, combined hormonal contraceptive vaginal ring, transdermal estradiol supplementation with gel, transdermal estradiol supplementation with patch, subcutaneous estrogen implant with cyclical oral progestogen. As the quality of available data is poor, further research is needed on this topic to improve the knowledge about the use of estrogens and progestogens in women with migraine. There is a need for better management of headaches related to the use of hormones or their withdrawal.

European headache federation consensus on the definition of resistant and refractory migraine

“…Trigger factors that can exaggerate migraine include alcohol consumption, caffeine overuse, diet, smoking and vasodilating antihypertensives. Further triggers are represented by emotional stress [37], alterations in the sleep cycle [38][39][40], and hormonal factors [41][42][43]. Management of those factors is a staple of good clinical practice.…”

Efficacy and safety of erenumab in women with a history of menstrual migraine

“…Continuous use of hormonal contraceptives can reduce the severity and duration of migraine attacks [14,[16][17][18]. Although hormonal contraceptives containing estrogens are considered a viable treatment option for women with menstrual migraine [19], evidence of their effectiveness is limited [20], and they may be contraindicated because of their association with increased risk of stroke [21][22][23][24]. According to the current guidelines, exogenous estrogens are contraindicated in all women with migraine with aura and in women with migraine without aura who are smokers and/or older than 35 years of age [25][26][27]; estrogen-containing options are therefore often not available to most women with migraine aged 35 or older [25,26].…”

Migraine start, course and features over the cycle of combined hormonal contraceptive users with menstrual migraine – temporal relation to bleeding and hormone withdrawal: a prospective diary-based study

“…In one trial with a shortened HFI of 4 days use of frovatriptan reduced headaches but was unexpectedly associated with delayed headache after the four HFI days [33]. Preventing estrogen withdrawal with continuous/ extended cycle is another management option that has been recommended for management of migraine during the HFI [34]. While a continuous combined CHC regimen might prevent migraine during the HFI, it would in contrast to use of the progestin-only pill with desogestrel, have no effect on migraine during hormone use.…”