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Hormonal Contraception in Women with Migraine Nappi et al. The Journal of Headache and Pain 2013, 14:66 http://www.thejournalofheadacheandpain.com/content/14/1/66 REVIEW ARTICLE Open Access Hormonal contraception in women with migraine: is progestogen-only contraception a better choice? Rossella E Nappi1,2,5*, Gabriele S Merki-Feld3, Erica Terreno1,2, Alice Pellegrinelli1,2 and Michele Viana4 Abstract A significant number of women with migraine has to face the choice of reliable hormonal contraception during their fertile life. Combined hormonal contraceptives (CHCs) may be used in the majority of women with headache and migraine. However, they carry a small, but significant vascular risk, especially in migraine with aura (MA) and, eventually in migraine without aura (MO) with additional risk factors for stroke (smoking, hypertension, diabetes, hyperlipidemia and thrombophilia, age over 35 years). Guidelines recommend progestogen-only contraception as an alternative safer option because it does not seem to be associated with an increased risk of venous thromboembolism (VTE) and ischemic stroke. Potentially, the maintenance of stable estrogen level by the administration of progestins in ovulation inhibiting dosages may have a positive influence of nociceptive threshold in women with migraine. Preliminary evidences based on headache diaries in migraineurs suggest that the progestin-only pill containing desogestrel 75 μg has a positive effect on the course of both MA and MO in the majority of women, reducing the number of days with migraine, the number of analgesics and the intensity of associated symptoms. Further prospective trials have to be performed to confirm that progestogen-only contraception may be a better option for the management of both migraine and birth control. Differences between MA and MO should also be taken into account in further studies. Keywords: Migraine with aura (MA); Migraine without aura (MO); Combined hormonal contraceptives (CHCs); Combined oral contraceptives (COCs); Progestogen-only contraception; Desogestrel-only pill; Venous thromboembolism (VTE); Stroke Introduction (GBD) recently published showed that migraine is the Migraine is a disabling headache, characterized by moder- seventh highest cause of disability in the world [2]. ate to severe head pain, usually accompanied by nausea, photophobia, phonophobia and osmophobia (migraine Review without aura, MO). In about 30% of patients migraine at- In the last few years significant advance in the field of tacks are preceded by transient focal neurologic symptoms reversible hormonal methods has been achieved in order which are called aura (migraine with aura, MA). Migraine to maximize the benefits and to minimize the risks. has a high socio-economical impact. In fact during mi- We believe it is relevant for clinical practice to briefly graine attacks most migraineurs reported severe impair- review in here potential vascular risks according to the ment or the need of the bed rest and almost 40% of category of migraine, with and without aura, and to the migraine patients have five or more headache days type of hormonal contraceptive option. monthly [1]. The Global Burden of Disease survey 2010 * Correspondence: [email protected] Epidemiology of migraine and combined hormonal 1Research Center for Reproductive Medicine, Gynecological Endocrinology contraceptive (CHC) use and Menopause, IRCCS S. Matteo Foundation, Pavia, Italy Migraine affects about 18% of women and 6% of men in 2Department of Clinical, Surgical, Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy USA and Western Europe [3,4] and its cumulative lifetime Full list of author information is available at the end of the article prevalence is 43% in women and 18% in men [5]. It is then © 2013 Nappi et al.; licensee Springer. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Nappi et al. The Journal of Headache and Pain 2013, 14:66 Page 2 of 6 http://www.thejournalofheadacheandpain.com/content/14/1/66 mostly a female disorder, that it is active in particular dur- extended/flexible regimens [25] or to use extended vaginal ing the fertile period of the women’ life with a peak of contraception [26]. prevalence in their 20s and 30s [6]. The reproductive life Very recently, Mac Gregor [27] reviewed the effects of is characterized by the need of reliable and convenient currently available contraceptive methods in the context methods of contraception. Among the several forms of of the risks and benefits for women with migraine and contraceptives available, hormonal contraceptives are the non-migraine headaches and concluded that for the ma- most popular reversible method, both in USA and Europe jority of women with headache and migraine, the choice and the “Pill” is the most used [7-9]. Low dose [20 to of contraception is unrestricted. Indeed, the contracep- 30 μg ethynil estradiol (EE2) per day] combined hormonal tive method is unlikely to have an impact on headache, contraceptives (CHCs) have become the method of choice whereas migraine deserves accurate diagnosis and rec- and the availability of new progestins (third- and fourth- ognition of the impact of different methods on such generation) has allowed to achieve non-contraceptive condition. benefits in comparison to older progestins (second – generation) [10]. CHCs are available in several regimens Vascular risks associated with CHCs and migraine and routes of administration (oral, transdermal vaginal) in MA, and to a lesser extent also MO, may increase vascular the attempt to improve tolerability, adherence and con- risk, especially the risk for ischemic stroke in younger venience of use [11]. Moreover, two new CHCs containing women [27-30]. Moreover, evidences that need to be cor- natural estradiol (E2), instead of EE2, have been intro- roborated by further studies suggest an association be- duced to increase safety and future developments are on- tween MA and cardiac events, intracerebral hemorrhage, going [12]. Interestingly, many gynecological conditions retinal vasculopathy and mortality [31]. Even though the that are comorbid with migraine can be treated with association between migraine and stroke appears to be CHCs. This enhances the likelihood of their use in mi- independent of other cardiovascular risk factors [32], the graine population [13]. The prescription of CHCs may presence of some risk factors, such as smoking and/or have different effects on migraine with not univocal results COCs use or their combination, further increase risk [33]. because of many methodological limitations (diverse hor- MA is associated with a twofold increased risk of ischemic monal combinations, variable research settings, retro- stroke but the absolute risk associated with CHC use is spective and/or cross-sectional designs, lack of a clear very low in healthy young women with no additional risk phenotyping of the headache according to IHS criteria, in- factors and mostly related to the estrogen dose [34]. In adequate duration of observation) [14-16]. Historically, spite of the considerable advances in terms of safety and combined oral contraceptive (COCs) is the category best tolerability of CHCs in migraine sufferers [13], their use is studied in migraineurs with an aggravation of migraine still questioned especially in women with additional risk reported in 18-50% of cases, an improvement in 3-35% factors for stroke, including, smoking, hypertension, dia- and no change in 39-65% [17]. A more recent cross- betes, hyperlipidemia and thrombophilia, age over 35 years sectional study on a large population found that migraine [35]. New evidences [36-38] have warned clinicians on the is significantly associated with COCs assumption. Yet use of CHCs and the risk of venous thromboembolism because of the design of the study it is not possible to de- (VTE) which is likely to be dependent on the type fine a causal relationship between exposure and disease of the progestin [RR 1.6–2.4 by using third- and [18]. Analysis on the different effect of the COCs on the fourth-generation CHCs (namely, desogestrel, gestodene two forms of migraine revealed that MA worsen more norgestimate and drospirenone, respectively) in compari- (56.4%) than MO (25.3%) [19]. Furthermore, women can son with those containing LNG (second-generation)] and present MA for the first time during the initiation of the total estrogenicity of CHCs [39,40]. Even new routes COCs [20]. During the last decade, a specific “window” of (trandermal patch and vaginal ring) seem to be associated vulnerability triggered by the 7 days free hormone interval with an increased VTE risk, but data are contradictory has been identified and the definition of hormonally- [41-43]. Indeed, according to a statement very recently re- associated headaches (exogenous hormone-induced head- leased [44] many factors contribute to VTE risk (e.g. age, ache and estrogen-withdrawal headache) encompasses duration of use, weight, family history) which makes epi- several patho-physiological mechanisms which are likely demiological studies vulnerable to bias and confounders. to explain nociceptive threshold in women [21,22]. Strat- In addition, the decision-making process should take into egies to minimize estrogen withdrawal at the time of account non only the small VTE risk (absolute risk de- expected bleeding or to stabilize circulating
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