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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

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.