Provider Education

How Do I Help My Patient Choose the Right Preventive Treatment?

 - by Nada Hindiyeh, MD via the American Headache Society

Migraine with Aura and Birth Control:

Unnecessary confusion still surrounds the use of combined hormonal contraceptives (CHCs) in the setting of migraine with aura (MwA). Clearing this confusion is a key issue for headache specialists, since most women with migraine have menstrual-related migraine (MRM), and some CHCs can prevent this particularly severe migraine. Their use, however, is still restricted by current guidelines due to concerns of increased stroke risk – concerns that originated over half a century ago in the era of high dose contraceptives. Yet studies consistently show that stroke risk is not increased with today's very low dose CHCs containing 20-25 µg ethinyl estradiol (EE), and continuous ultra low-dose formulations (10-15 µg EE) may even reduce aura frequency, thereby potentially decreasing stroke risk.

This article clarifies the stroke risk of CHCs and examines their impact on migraine. It also examines how stroke risk is altered by the estrogen content of the CHC, by contributing factors such as smoking, age and hypertension, and by aura frequency. And finally, it puts these risks into a meaningful context with a risk/benefit assessment.

Review article: Calhoun, A. Hormonal Contraceptives and Migraine with Aura---Is There Still a Risk? Headache. 2017;57:184-193. PMID: 27774589

Menstrual Migraine Strategies:

Limiting the difference in estrogen content between the active pills and placebo to ≤10 μg of ethynyl estradiol (EE) helps prevent menstrual migraine. 

CHC regimens with declines of ≤10 μg EE include the following options:

(1)  Monophasic: 

Examples include 

• Lo Loestrin Fe®: 2 day pill-free interval monthly with 10 mg EE drop- norethindrone/ethynyl estradiol 1mg/10mcg days x24 days, then norethindrone/ethynyl estradiol 0mg/10mcg x2 days, then ferrous fumarate 75mg x2 days
• Amethyst®: no decline, continuous active 20mg EE pills- levonorgestrel/ethynyl estradiol 0.9mg/20mcg x28 tab

(2)  Monophasic Extended Dose Packs: 91-day extended cycle pack with 10 mg EE decline in week 13. Several brands of this combination dosing are available on the market.

• Levonorgestrel/ethynyl estradiol 0.1mg/20mcg x84 days, then 0mg/10mcg for 7 days
  

(3)  Quadriphasic: 

Examples include

• Natazia®: 3 successive drops in estradiol valerate (EV), each about 6.5ug EE decline- estradiol valerate/dienogest 3mg/0mg x2 days, then 2mg/2mg x5 days, then 2mg/3mg x17 days, then 1mg/0mg x2 days, then inert tab x2 days

(4)  Can also use the following combination which limits estrogen drop to ≤10 μg EE: 

• Norethindrone/ethynyl estradiol 1mg/20mcg x24 days then ferrous fumarate x4 days at bedtime AND Premarin (conjugated estrogens) 1.25mg at bedtime days 25-28 
• There are many brands of this Norethindrone/ethynyl estradiol formulation available; we find that one commonly used one is Junel Fe 24® but please use your preferred CHC with similar dosing

An Evidence-Based Approach to the Diagnosis and Management of Migraines in Adults in the Primary Care and General Neurology Setting

This online CME activity provides a practical approach to the diagnosis and management of migraine for primary care providers and general neurologist. We will cover key concepts in the diagnosis and management of migraine through an online interactive video-based course with cases to reinforce your knowledge. Migraine is a type of chronic headache disorder which requires ongoing maintenance to prevent attacks. It is one of the most disabling conditions and a common disorder evaluated by primary care physicians and general neurologists. The diagnosis of migraine and standard of care treatment approaches including pharmacologic and nonpharmacologic strategies will be reviewed. Patient and family counseling as well as educational resources for patients will also be provided upon completion of the course.