Migraine Anne MacGregor 1 Contraception and Migraine Prof Anne MacGregor Barts 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 al Ne uro l og y2 0 03 ;6 1:3 75 -8 2 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 al Ne uro l og y2 0 03 ;6 1:3 75 -8 2 Dodick D Se mi n Neu ro l 2 0 10 ;30 :7 4 - 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% attacks 1% without headache Migraine without aura Migraine with aura 70-80% attacks
Transcript
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
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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 )
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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
