Headaches are common! Contraception and Migraine...• Be able to diagnose migraine with and without...

Migraine

Anne MacGregor 1

Contraception and Migraine

Prof Anne MacGregorBarts Health NHS Trust &

Barts and the London School of Medicine and Dentistry

www.annemacgregor.com

Headaches are common!

• Do you get headaches that last from a few hours to a few days?

• Do you otherwise feel fine?

Do you have the following with your headaches?

• Light bothers you more than usual?• Your headaches limit your ability to work,

study or do what you need to do?• You feel nauseated or sick?

Lipton et a l Neuro logy 2003;61:375-82

PIN migraine

• Headache attacks associated with– Photophobi a– Impairment of function– Nausea/vomiti ng

• “Fine” between attacks

Positive predictive value for migraine diagnosis: 2 positive answers – PPV = 93% 3 positive answers – PPV = 98%

Lipton et a l Neuro logy 2003;61:375-82Dodick D Semin Neuro l2010;30:74-81

By the end of the talk you should …

• Be able to diagnose migraine with and without aura

• Know the risk of ischemic stroke associated with migraine with without aura

• Know what contraception can be used by women with migraine aura

20-30% attacks1% without headache

Migraine without aura Migraine with aura

70-80% attacks

Migraine

Anne MacGregor 2

• 20-30% attacks• 1% without headache

Migraine without aura Migraine with aura

• 70-80% attacks

What’s the difference?

normal premonitory headache resolution recovery normal

headache

foodcraving

tired/yawning

heightenedperception

anorexia/nausea/vomiting

malaise/ lethargy

photoandphonophobia

heightenedsenseofsmell

vomiting

s leep limitedfoodtolerance

tired

diures is

poorconcentration

difficultyfocus ing

irritable

hungover

drugs

2-24 hrs

Migraine without aura

s tiffneck

poorconcentration

Blau J N Lanc et1992;339:1202-7

2-24 hrs4-72 hrs

normal premonitory aura headache resolution recovery normal

headache

foodcraving

tired/yawning

heightenedperception

anorexia/nausea/vomiting

malaise/ lethargy

photoandphonophobia

heightenedsenseofsmell

vomiting

s leep limitedfoodtolerance

tired

diures is

poorconcentration

difficultyfocus ing

irritable

hungover

drugs

2-24 hrs

Migraine with aura

<1hr

s tiffneck

poorconcentration

2-24 hrs4-72 hrs

Blau J N Lanc et1992;339:1202-7

• 20-30% attacks• 1% without headache

Migraine without aura Migraine with aura

• 70-80% attacks

Why does aura matter?

Relative risk of ischemic stroke

2,16 2,25

1,23 1,24

0

1

2

3

4

Effe

ct s

ize

(95%

CI)

Migraine withAura

Migraine without Aura

Combined oral contraception and ischemic stroke

• Prothrombotic effect• Increased risk of ischemic stroke

– 30-40mcg EE: OR 1.75 (95% CI = 1.61-1.89)– 20mcg EE: OR 1.56 (95% CI = 1.36-1.79)

• Avoid additional risk factors

Xu Z et a l Thromb Res 2015;136:52-60

EE = ethinylestradiol

Migraine

Anne MacGregor 3

Migraine aura contraindicates use of combined hormonal contraception

Is it aura?

normal premonitory aura headache resolution recovery normal

headache

foodcraving

tired/yawning

heightenedperception

anorexia/nausea/vomiting

malaise/ lethargy

photoandphonophobia

heightenedsenseofsmell

vomiting

s leep limitedfoodtolerance

tired

diures is

poorconcentration

difficultyfocus ing

irritable

hungover

drugs

2-24 hrs

When does a migraine start?

2-24 hrs

s tiffneck

Blurredvis ion

4-72 hrs

Blau J N Lanc et1992;339:1202-7

premonitory

foodcraving

tired/yawning

heightenedperceptionirritable

2-24 hrs

When does a migraine start?

s tiffneck

Blurredvis ion

Blau J N Lanc et1992;339:1202-7

28% report bl urred visi on

headache resolution

headache

foodcraving

tired/yawning

heightenedperception

anorexia/nausea/vomiting

malaise/ lethargy

photoandphonophobia

heightenedsenseofsmell

vomiting

s leep limitedfoodtolerance

tired

diures is

poorconcentration

difficultyfocus ing

irritable

hungover

drugs

Headache phasevisual symptoms

4-72 hrs

s tiffneck

Blurredvis ion35% report

blurr ed vi sion

Blau J N Lanc et1992;339:1202-7

Gi ffin N et a l Neuro logy 2003;60:935-40

Is it aura?

• lasting >1 hour • before and/or

during headacheare

NOT aura

Generalised spots or blurred vision

Migraine

Anne MacGregor 4

Migraine aura

• 99% visual• Scintillating

scotoma/fortification spectra• Starts before the headache• Lasts less than 60 minutes -

typically 20-30 mins

Sc hott GD. Brain 2007;130:1690-1703

You don’t need eyes to ‘see’ an aura……

Cortical Spreading Depression

3mm/min

Lauri tz en M TINS 1987;10:8-13Las hley KS Arch Neurol Psy ch 1941;46 :331-9

What you ‘see’

Migraine

Anne MacGregor 5

Sensory aura• Unilateral• Starts in hand and

progresses up arm into face and tongue

• Lasts 30-60 minutes• Rarely affects leg• Rarely occurs in

absence of visual symptoms

TIME the aura

• Visual disturbances– Start before a headache– Last less than one hour

DRAW the aura

Progestogen-only contraception

• Not associated with any significant alteration in hemostasis

• Not associated with an increased risk of ischemic stroke– OR 0.99 (95% CI = 0.71-1.37)

Xu Z et a l Thromb Res 2015;136:52-60

POP in migraine with and migraine without aura

Age(years ± SD)

No. ofmigraine days/month(mean ± SD)

P

Baseline Days 1-90 Days 91-180

Desogestrel75mcg(n=42)

30.3± 2.9 5.8± 4.3 3.7± 3.4 3.6± 4.0 <0.001

Merk i -Feld G et a l . J Headac he Pain 2015;16 :39

Retrospective analysis of contemporaneous chartsMigraine with aura (n=10)

Migraine without aura (n=32 )

Migraine

Anne MacGregor 6

POP vs extended cycle COC in migraine without aura

Age(years ± SD)

No. ofmigraine days/month(mean ± SD)

P

Baseline6th monthoftreatment

EE 20mcg +Desogestrel 150mcg

(n=22)29.4± 3.3 5.1± 2.2 4.1± 2.2 NS

Desogestrel 75mcg(n=31)

30.3± 2.9 5.5± 2.6 3.5± 1.2 <0.001

Morotti M et a l . Eur J Obstet Gy necol ReprodBio l2014;183 :178-82

Retrospective analysis of contemporaneous charts

POP in migraine with aura

Age(years ± SD)

Age at auraonset

(years ± SD)

No. ofmigraine attacks/month(mean ± SD)

P

3/12baseline

6th monthof75mcg desogestrel

Previous COC(n=15)

31.5± 6.5 30.9± 6.4 3.9± 1.0 2.9± 0.8 <0.001

Never COC(n=15)

30.6± 5.4 17.7± 5.8 3.2± 0.9 2.6± 1.3 <0.02

Nappi R et a l Contraception2011;83:223-8

Prospective diary-based study

Summary

• Migraine aura (but not migraine without aura) is associated with a 2-fold increased risk of ischemic stroke

• For women with migraine with aura– Contraceptive use of CHCs is contraindicated– Consider progestogen- only contracepti on

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