#menstrual #migraines and #contraception for migraine with #aura

Treatment of mentrual migraines can be tricky. They are often felt as more intense, they have a long duration and they do not respond well to treatment. When they do not respond to the recommended treatments (see links below for full list of treatments) sometimes doctors suggest going on birth control to halt the drops in estrogen.

Is this an effective tool against menstrual migraines? We have heard many people say it makes them worse. Others say it helped a great deal. It seems rather confusing.
Migraine and oral contraceptive use continues to be a source of controversy. Oral contraceptive initiation may worsen or change the pre-existing pattern of migraine. In a small percentage of women, there may be improvement or no change at all. The concern of oral contraceptive use is twofold; how will it affect the migraine severity and frequency; and what is the added risk of stroke to the migraineur on the pill. Migraine may be affected by the pill in one of five ways; attacks may begin for the first time; pre-existing migraine may worsen; there may be an alteration in the pattern; migraine may improve and finally there may be no change. Some studies have suggested there is no change in headache with the oral contraceptive. Help for Headaches
It seems everyone is in fact right on this one. Many of us get worsening headaches. A small percentage get improvement and many notice no difference at all. Yet if we are at the point where other treatments have failed and these menstrual migraines are brutal what sort of options can we choose that may benefit us in this area?

Taking the Pill continuously

Dr Anne MacGregor discusses this in her books ‘Migraine and Women’ and ‘Migraine and Other Headaches’. She explains that taking the Pill continuously can stop migraines. However, because there is no controlled withdrawal bleed, unpredictable breakthrough bleeding may occur.
In Dr MacGregor’s words: ‘there is little evidence that the monthly breaks from the pill are associated with any added health benefits and that the benefits of reduced menstrual problems and increased efficacy are clear’.

The combined contraceptive pill and the risk of stroke

If you suffer from migraine with aura you should not take the combined oral contraceptive Pill. This is because the combined pill is associated with a very small increased risk of ischaemic stroke. This risk increases when the Pill is taken by women who have additional risks for stroke, such as smoking and migraine with aura. Statistics show that the risk is extremely small but never-the-less it is still a risk, which can be avoided. The risk from the Pill is due to ethinyloestradiol, and not progestogen. So progestogen-only contraceptives are a safer alternative. Some of these are more effective contraceptives than the combined Pill.

Progestogen–only pill

You may consider taking this form of contraception if you are unable to take the combined pill. Although this method suits many women, others find that erratic bleeding is a problem. This can, in turn, lead to more headaches. The Migraine Trust
I should point out in the case with migraine with aura my doctor said All estrogen based ones were Out of the question. Studies on migraines and stroke risk with migraines and aura being how they have been lately she would only put me on the Progesterone only pills.

Progestin methods are safe
The use of progestin-only methods has been promoted in headache sufferers, especially those who have a specific diagnosis of migraine, because progestins do not add to the elevated risk of stroke that accompanies migraine with aura.
Because headache is common in women of reproductive age, it is not surprising that it is listed as a common adverse event for all contraceptives, including progestin-only methods. Evidence that progestin-only methods cause or worsen headaches is slim, however. Preliminary studies indicate that mid-luteal elevations of progesterone or its metabolites could prevent migraine, compared with other times in the cycle.6 Older studies report that a daily oral progestin could prevent migraine in premenopausal women, possibly secondary to induction of anovulation. At the same time, there are clinical reports that DMPA may trigger headache as a side effect in susceptible women.
Generally, then, although progestin-only methods are likely to be safe in all patients with headache, and ovulation suppression may improve the headaches, some patients may experience worsening symptoms. OBG Management
I had worried there was in fact a difference between the two in there effectiveness to treat migraines. Estrogen based vs progesterone based. From what I have found they have equal potential, or not potential. The issue only raised with depo shots is the irregular bleeding which seems to cause breakthrough migraines and the bleeding can be very irregular.

Progestogen-only contraception: a class on its own

The progestin component of hormonal contraceptives accounts for most of their contraceptive effects (inhibition of ovulation, suppression of endometrial activity, thickening of cervical mucus). Progestin-only methods includes pills (the pill most used in Europe contains low doses of desogestrel), injectables [depot Medroxyprogesteroneacetate (DMPA)], implants (the most recent long-acting reversible contraception contains Etonogestrel single-rod implant for at least 3 years), and intrauterine devices (levonorgestrel for at least 5 years) [48]. By providing effective and reversible contraception, progestin-only contraception has many noncontraceptive health benefits including improvement in dysmenorrhea, menorrhagia, premenstrual syndrome, and anemia [49]. Indeed, there is a general reduction of the amount of menstrual bleeding but cycle control may be erratic, a feature that may influence acceptability [50-52]. Progestin-only methods are appropriate for women who cannot or should not take CHCs because they have some contraindications to estrogen use and therefore display a higher risk of VTE [35,36]. The progestogen-only contraception is a safe alternative to CHCs and the avoidance of the estrogen component has many advantages not only for breastfeeding women but also for women with vascular diseases or risk factors for stroke [46,47]. The use of progestin-only contraception is not associated with an increased risk of VTE compared with non-users of hormonal contraception [53]. In addition, progestin-only pills, injectables, or implants are not associated with increased risk of ischemic stroke according to a recent metanalysis (OR 0.96; 95% CI: 0.70-1.31) [54]. Since the 1-year prevalence rates for migraine in women are 11% for MO and 5% for MA, respectively [55], there is potentially a high number of women in whom CHCs may be contraindicated according to WHO guidelines and progestogen-only contraception may be safely used [35,36].

Evidence of progestogen-only contraception in women with migraine

Given the evidence that progestogen-only contraception is a safer option for women with migraine, the main question is whether such contraceptive choice may influence the course of both MA and MO and offer a better management of the disease. Indeed, even though the excess risk of death for a woman taking modern CHCs is 1 in 100,000, which is much lower than the risk of everyday activities such as cycling [56], there is a biological plausibility that in women with migraine should be wiser to use an estrogen-free containing contraception to avoid any potential vascular risk. Two recent very large epidemiologic studies [36,57] reported the association between CHC and progestogen-only methods and cardiovascular risk, thrombo-embolic risk and stroke. Whereas no increased risk for deep venous thormbosis, myocardial infarction and thrombotic stroke was found for the progestogen-only methods, the risk were two-sixfold elevated in CHC users. The role of progesterone/progestins in the pathophysiology of migraine has been overshadowed by Somerville’s early observations that it was the prevention of estrogen but not of progesterone withdrawal in the late phase of the cycle to be able to prevent the occurrence of migraine attacks [58,59]. Indeed, at variance with the influence of estrogens upon the cerebral structures implicated in the pathophysiology of migraine [60], cyclic variations in progestin levels were not related to migrainous headaches, but they rather seem to be protective. Progesterone apparently attenuates trigemino-vascular nociception [61] and its receptors are localized in areas of the central nervous system, which are involved in neuronal excitability and neurotransmitter synthesis release and transport [62]. It has been shown that progesterone can antagonize neuronal estrogenic effects by downregulating estrogen receptors [63]. Whereas estrogen peak decrease the threshold for cortical spreading depression (CSD), the neurobiological event underlying MA, estrogen withdrawal increased the susceptibility to CSD in an animal model [64]. Therefore, the maintenance of low estrogen levels and the avoidance of estrogen withdrawal by the administration of progestins in ovulation inhibiting dosages might decrease cortical excitability. Indeed, progestogen-only contraception has a continuous administration, without the hormone-free interval, and does not induce withdrawal stabilizing circulating estrogens, but some fluctuations according to different preparations may still occur [65]. Clinical data are scarce and no comparative studies with progestogen-only contraceptives and placebo or COCs are available in the literature [27]. Diagnoses are often inaccurate, without distinction between headache and migraine, and headache is reported in contraceptive progestin implant users as a potential cause of discontinuation [66]. Similarly, there is an increase in headache, but not migraine, reported over time with both norethisterone enanthate and, especially with depot medroxyprogesterone acetate [67]. Anecdotally, migraine is more likely to improve in women who achieve amenorrhea [68]. In a large, cross-sectional, population-based study in Norway of 13944 women, a significant association between CHC and headaches, but no significant association between progestin-only pills and migraine (OR 1.3, 95% CI: 0.9–1.8) was found but the number of users was small [18]. To date two diary-based studies pilot studies on the effect of desogestrel 75 μg on migraine have been published [69,70]. Such oral daily pill inhibits ovulation and the dose allows the ovary to synthesize stable amounts of estrogen which are relevant for wellbeing and bone density [71]. The first study included thirty women with MA [69]. The use of desogestrel 75 μg resulted in a significant reduction in MA attacks and in the duration of aura symptoms, already after three months of observation. Interestingly, the beneficial effect of desogestrel 75 μg on visual and other neurological symptoms of aura was significantly present only in those women in whom MA onset was related to previous COCs treatment. These findings suggest that the reduction in estrogen levels may be relevant to the amelioration of MA, but do not exclude a direct effect of the progestin on CSD. The second study on the effect of desogestrel 75 μg included women with MA (n°=6) and with MO (n°=32) and evaluated migraine days, pain score and pain medication [70]. An improvement of each parameter was observed during 3 months use of desogestrel 75 μg in comparison to a three months pretreatment interval. A subanalyses of the effect on 32 women with MO revealed significant improvements in number of migraine days, pain medication and pain intensity. The mean number of migraine attacks at baseline was higher in comparison to that in the study of Nappi et al. [69], indicating that also very severe migraineurs might profit from such a progestin-only contraception. Chronic migraineurs often develop medication overuse headaches with severe limitation of their quality of life. The reduction of pain medication by progestin-only contraception is an interesting approach and it should be studied further. Indeed, there is a broad variation in the intensity of improvement with a reduction in migraine frequency ranging from 20% and 100% [70]. No indicators to identify those women who will profit from desogestrel 75 μg could be ascertained. On the other hand, there were few dropouts of women experiencing more migraine after starting contraception with this progestin in both studies, indicating that progestins can also deteriorate migraine in few cases.
A very recent study investigating the changes of quality of life in migraineurs 3 months after initiation of the progestagen-only pill desogestrel 75 μg demonstrates a highly significant reduction in Midas Score and Midas grades [72]. However, clinical experience with desogestrel 75 μg in migraineurs further shows that during the initial 4 weeks migraine frequency can raise slightly before headaches improve. This information has to be mentioned and discussed during counseling.
In summary, the potential advantages of using progestogen-only contraception in women with migraine are the following:
1) Continuous use
2) Absence of estrogen peak
3) No influence on threshold for cortical spreading depression (CDS)
4) No evidence of increase in cardiovascular, stroke and thrombo-embolic risk
5) No data on progestins inducing migraine

More complete info on all treatment methods for menstrual migraines:

Ribbins Headache Clinic: Menstrual migraines

National Headache Foundation: Menstrual Migraine

Hormonal Contraceptive Options for Women With Headache: A Review of the Evidence
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