Migraine and contraception

Hormones used for contraception can affect migraine – so what’s the best choice?

What types of contraception are best for migraine?

Because different types of contraception work in different ways, each can have its own effects on migraine. Understanding how each method works can help you make the best choice for contraception, sometimes even with benefits for migraine.

There are two main types of contraception: hormonal and non-hormonal.

Hormonal methods include combined hormonal contraceptives (CHCs), which contain a combination of oestrogen and progestogen.

These are usually taken for 21 consecutive days before a seven-day hormone-free interval. During the break a withdrawal bleed (like a period) will occur.

They are very effective methods of contraception as their main effect is to stop ovulation (the release of an egg from the ovaries) each month.

CHC is very safe for most women, including most women with migraine. It is not suitable for women who are at a higher background risk of blood clots, including those who smoke, have high blood pressure, or are very overweight.

Importantly, due to the increased risk of blood clots, CHC is also unsuitable for those who have migraine aura, since the oestrogen component can further increase the risk.

Other hormonal methods contain only progestogen and are usually suitable for women who are unable to, or don’t want to, take oestrogens. The most effective methods work in the same way as the CHCs, inhibiting ovulation. These include:

• An implant, which lasts for three years
• An injection, which lasts for three months at a time
  The progestogen-only pill (POP), which is taken every day without a break and contains the progestogen desogestrel
• The levonorgestrel intra-uterine system, which is inserted into the neck of the womb, slowly releasing progestogen into the lining of the womb over its lifespan (three or five years). This keeps the lining of the womb thin so that periods can be light or even absent. The normal hormone cycle continues as ovulation is not inhibited.

The progestogen-only pill, or ‘mini-Pill’, does not reliably prevent ovulation but helps the mucous secretions from the cervix stay thick and so impenetrable to sperm. Menstrual cycles can be erratic, although a few women find that their periods stop completely.

The copper intra-uterine device remains a highly effective, non-hormonal method of contraception. However, it can cause increased and prolonged menstrual bleeding, which can worsen migraine.

Sterilisation, condoms, caps (diaphragms) and natural family planning methods aren’t linked with any change in the pattern of migraine.

How do contraceptives affect migraine?

Migraine and contraception may be linked wherever contraception affects hormones.  Headache is a common symptom during the early months of using hormonal contraception but usually resolves with time.

If attacks occur, they tend to come during the hormone-free week. Some women, usually those with aura, note a worsening in the frequency or severity of attacks. A few women develop aura for the first time.

Migraine and the Pill

Is the Pill safe for migraine sufferers? For the majority of women, CHCs are highly effective and safe methods of contraception. There can be some added health benefits such as reduced risk of womb, ovarian and bowel cancers, lighter menstrual periods and relief from premenstrual symptoms.

Some women even take CHCs to help treat menstrual migraine.

However, for a minority of women, including those who have migraine with aura, CHCs are associated with an increase in the risk of stroke. Fortunately, the actual likelihood of a stroke occurring in a young woman with migraine with aura who takes ‘the Pill’ is extremely low. It is also an avoidable risk, since most contraceptives that do not contain oestrogen are at least as effective as CHCs – and some are more effective.

So how great is the risk of taking the Pill with migraine? Research suggests those with migraine, and particularly migraine with aura, have about twice the risk of having an ischaemic stroke when compared with people who don’t have migraines. However, it is worth pointing out that these risks are very low, particularly if you do not smoke, are a healthy weight and don’t have high blood pressure. But since non-oestrogen methods of contraceptive work just as well, the increased risk is best avoided.

The World Health Organization has made recommendations to ensure safe prescribing of CHCs by identifying women at risk of arterial thrombosis and, where the risks outweigh the benefit of the method, offering alternative contraception. Due to the increasing choice of methods available, there should be no loss of contraceptive efficacy. A history of aura at any time, even if it occurred during childhood, has been deemed an unacceptable risk factor.

I can often sense I’m going to get a migraine – is this an aura?

Migraine with aura accounts for 20 to 25 per cent of migraines – in about one per cent of cases there is no headache. The symptoms of aura are usually visual, developing gradually over five to 20 minutes and lasting for less than one hour before disappearing.

People usually describe the visual aura as starting from a small, just off-centre bright spot, which enlarges to a bright, curved, zig-zag line (scintillation).

The scintillations can flicker with the brilliant intensity of a fluorescent bulb.

Within these lines, vision can be dark or blank (scotoma).

Sensory symptoms, such as feeling ‘pins and needles’ spreading up the arm from one hand and into the mouth, or difficulty finding the right words, can also occur.

After the aura subsides, a typical migraine headache usually ensues, although sometimes the headache that follows is not a migraine-type headache or there may be no headache at all.

The crucial characteristics of aura are the duration and timing of symptoms in relation to the onset of migraine headache.

Aura should not be confused with the more common symptoms that can help you spot that a migraine is on its way one or two days before the actual attack.

If you’re not sure whether your warning symptoms are aura, ask yourself the following.

Do you ever have visual disturbances that:

• start before the headache?
• last up to one hour?
• resolve before the headache?

If you answer ‘yes’ to all three questions, it’s likely that your symptoms are aura. Speak to your GP or a headache specialist at the National Migraine Centre if you’re at all unsure.

What causes migraine in the ‘Pill-free’ week?

Migraine occurring exclusively in the hormone-free week is probably triggered by falling levels of oestrogen.

These attacks tend to be migraine without aura and usually begin a couple of days after the hormones are stopped.

If acute treatment, isn’t enough to control the symptoms, hormonal treatments may help.

What can I do to help myself?

For the majority of women with migraine who are using hormonal contraception, the advice for reducing the impact of migraine is no different from our standard advice, which you can find on our other National Migraine Centre factsheets.

This means treating attacks with appropriate painkillers and keeping a headache diary to establish the pattern of attacks and to identify non-hormonal triggers.

Often, effective acute treatment is usually all that is necessary, particularly if attacks only occur once or twice a month.

What can my doctor do to help me?

If painkillers are not effective, your doctor can prescribe a number of different treatments including anti-sickness drugs (which can help the painkillers work more effectively), prescription non-steroidal anti-inflammatory painkillers and triptans.

If acute treatment is inadequate to control your symptoms, you can speak to your doctor about hormonal approaches to preventing attacks. Although there is limited evidence to support the following suggestions, they are widely used by doctors

First of all, you can try changing the way you take your pill. There are two options which can be used separately or in combination:

• The ‘tri-cycle’ regimen, where three consecutive hormone cycles are taken (without the traditional seven-day break), followed by a hormone-free interval. This means that you would have only five such migraines a year instead of thirteen. In some countries, CHC pills are licensed for a 91-day cycle of 84 days of pill-taking followed by a seven-day break, resulting in only four pill-free intervals each year.
• The four-day break, where instead of taking 21 days of the pill followed by a seven-day withdrawal period, you break the cycle for four days. This has been shown in trials to reduce the fall in oestrogen levels and may lessen the likelihood of a menstrual migraine occurring.

A second option is to using natural oestrogen supplements during the hormone-free interval. This provides some protection against oestrogen withdrawal, while enabling a progestogen withdrawal bleed to occur. Types of oestrogen available include 100μg patches twice within the hormone-free week, 1.5mg gel daily, or 2mg oral oestradiol valerate daily during the pill-free interval.

Key points

• Combined hormonal contraceptives (‘the Pill’ and ‘the Patch’) are safe for healthy, non-smoking women with migraine without aura.
• Combined hormonal contraceptives shouldn’t be used by women who have migraine with aura because of an increased risk of ischaemic stroke.
• Progestogen-only and non-hormonal methods of contraception are not associated with an increased risk of ischaemic stroke.
• Some progestogen-only and non-hormonal methods are more effective contraceptives than combined hormonal contraceptives.

Listen to our Heads Up podcast special episode 1 in series 2 for more information on hormones and migraine.

Book an appointment with the experts: a consultation with a leading headache specialist, with an understanding of women’s health, contraception and migraine, could help you get on top of migraine. Book your consultation now.