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Effects of Migraine and Contraception

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Headache is a common condition affecting the majority of women at some time in their lives. Epidemiological studies of migraine also confirm that up to one-third of women will experience migraine, particularly during their fertile years. Studies suggesting that migraine in young women is associated with an increased risk ischaemic stroke have led to particular concerns regarding the additional effect of other risk factors such as use of combined oral contraceptives.

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Migraines are more common in women than in men and the difference is more common in the reproductive years. The main reason for this is the role of the female sex hormone which implicates the menstrual cycle as a significant migraine trigger for women. Sex hormones, oestrogen and progesterone, and the physical and chemical processes that go towards producing them, all have a widespread effect on your body and as the contraceptive pill is made up of similar hormones there will be an effect on your migraines. Some women are more sensitive to the fluctuations within the menstrual cycle. Studies suggest, for example, that migraine can be triggered by a drop in your oestrogen levels such as those which naturally occur in the time just before your period and the result of falling oestrogen levels in the later phase of the menstrual cycle. It is important to mention that headaches are a common side effect of taking oral contraceptives and in that case usually improve over time. They can be affected by the dose and type of hormone in the pill

Some women find that their headaches and migraines improve when they start the pill; others notice that their headaches and migraine get worse. Studies suggest that headaches are less likely to occur with the lowest dose pills (20 micrograms of oestrogen) containing newer types of progestogens but this is not the same for everyone. It is important to find the pill that suits you best. This type of contraceptive pill is made up of a combination of a particular type of oestrogen, called ethinyloestradiol, and a particular type of progesterone, called progestogen. The Pill was introduced over 40 years ago, and the amount of hormones is now much lower than in the past . This has meant that unwanted effects like headaches and migraines, are much less likely to occur when they take the Pill. However, for many women their migraine attacks become more severe or frequent during the week they do not take the Pill. This is because the hormone levels drop at this time. The drop in oestrogen can trigger the migraine. If you get 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.

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In women who start combined hormonal contraceptives for contraception and who develop new onset of migraine with aura, or who develop new onset migraine without aura in a temporal relationship to starting the hormonal contraceptive, we suggest switching to non-hormonal contraception (condoms, copper-bearing intrauterine device, permanent methods) or progestogen-only contraceptives (oral pill, subdermal implant, depot-injection, and levonorgestrel-releasing intrauterine system). Weak recommendation, Low quality of evidence. It is well known that combined HCs may impact on the course of migraine; the impact may consist of worsening of previous migraine, in developing de novo migraine (with or without aura), or in some cases in improving migraine. Some women do not experience any headache change associated with the use of combined HCs. Some women do appear to have a higher risk of headache exacerbation or new-onset headache attributable to combined HC use. This mostly occurs with the use of combined HCs that provide a drop estrogen that is equivalent to the end-luteal phase drop. This higher risk is most apparent in women with a strong personal or family history of troublesome headaches, particularly migraine. The risk also increases with age. Even within the higher risk groups, some women note improvement in headache with combined HCs use. In several women reporting initial worsening, headache complaints decrease with continued use (Samaan Z, MacGregor EA, 2010). It is not always easy and obvious to establish a clear relationship between migraine onset or worsening and use of combined HCs. In fact, migraine typically starts in teens/twenties, so association with HCs use may be coincidental. It is worth to consider that any change in migraine pattern is only likely to be associated with hormone use if there has been a clear temporal relationship

An increase in migraine frequency several years after starting HCs is more probably associated with independent, non-hormonal triggers. Headache that is related to combined HCs use generally is precipitated by estrogen withdrawal during the pill-free or placebo pill week of treatment and causal relationship is probably more definite when attacks occur regularly during hormone-free interval. Continuous treatment may ameliorate attacks occurring in the pill-free or placebo pill interval of treatment. There are no studies which have addressed whether changing from migraine without aura into migraine with aura, associated with initiation of combined HC, is associated with an increased risk of vascular events including ischemic stroke. However, there are some old data, from studies of high-dose combined HCs, which suggest that the development of migraine aura in women using those compounds correlates with increased platelet activation (Fritsche G, Hueppe M, 2007).

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On the whole, such information was not provided in detail in our database. (iv) The changes in OCP use (starting, switching, and stopping) might have an impact on migraine symptomatology. Additionally, migraine patients with menstrually-related worsening may use COC with a different regimen, for example, extended duration. Our study design cannot answer these questions. (v) Patients without COC use might already have had contraindications to COC, which might affect the migraine symptomatology. This cannot be answered in the current study design. Our data provide real-life OCP use behavior among migraine patients and add evidence to the hypothesis that use of OCP is associated with certain differences in symptoms of migraine. Future studies should focus on the type of hormone/s, dose and regimens, and their respective impact on the migraine symptoms and sensitivity changes.

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Fritsche G, Hueppe M, Kukava M, Dzagnidze A, Schürks M, Yoon MS, Diener HC, Katsarava Z. Validation of a German language questionnaire for screening for migraine, tension-type headache, and trigeminal autonomic cephalgias. Headache. 2007

Samaan Z, MacGregor EA, Andrew D, McGuffin P, Farmer A. Diagnosing migraine in research and clinical settings: the validation of the structured migraine interview (SMI) BMC Neurol. 2010;10:7.

Lipton RB, Dodick D, Sadovsky R, Kolodner K, Endicott J, Hettiarachchi J, Harrison W, Migraine validation study ID. A self-administered screener for migraine in primary care: the ID migraine validation study. Neurology. 2003;

Brighina F, Salemi G, Fierro B, Gasparro A, Balletta A, Aloisio A, La Pegna G, Randisi G, Saporito V, Calagna G, La Naia F, Morana R. A validation study of an Italian version of the "ID migraine". Headache. 2007;

Karli N, Ertas M, Baykan B, Uzunkaya O, Saip S, Zarifoglu M, Siva A; MIRA study group The validation of ID migraine screener in neurology outpatient clinics in Turkey. J Headache Pain. 2007;8:217–223

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