MIGRAINE WITH AURA

Dr Jill Zelin for Prof Anne MacGregor

Barts Health NHS Trust & Barts and the London School of Medicine and Dentistry

www.annemacgregor.comUK.PH.GM.X.2012.042d April 2012

OVERVIEW

What is migraine?What are the risks of hormonal contraception in women with migraine?What are the effects of hormonal contraceptives on migraine?

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 for at least one day?You feel nauseated or sick?

Lipton et al Neurology 2003;61:375-82

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

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 for at least one day? You feel nauseated or sick?

Lipton et al Neurology 2003;61:375-82

• 20-30% attacks• 1% without

headache

MIGRAINE

Migraine without aura Migraine with aura

• 70-80% attacks

IS IT AURA?

normalI

premonitoryII

auraIII

headacheIV

resolutionV

recovery normal

headache

food craving

tired/yawning

heightenedperception

anorexia/nausea/vomiting

malaise/ lethargy

sensitive to light/sound

heightened sense of smell

vomiting

sleep limited foodtolerance

tired

diuresis

poor concentration

difficulty focusing

fluid retention

hungover

drugs

2-24 hrs

WHEN DOES A MIGRAINE START?

Blau JN Lancet 1992;339:1202-7

<1 hr 4-72 hrs 2-12 hrs 2-24 hrs

PREMONITORY VISUAL SYMPTOMS

100

80

60

40

20

0

-150 -100 -50 0 50 100

premonitory

headache

Giffin N et al Neurology 2003;60:935-40

hours

VA

S r

atin

g o

f st

ate

of

hea

lth 28% reported blurred vision

49% reported light sensitivity

MIGRAINE AURA

99% visualScintillating scotoma Important points

Relationship to headacheStarts before Resolves before

DurationLasts less than 60 minutes - typically 20-30 mins

Symptoms are specific

DIAGNOSIS

Do you ever have visual disturbancesStarting before the headache?*Lasting up to one hour?Resolving before the headache?*

*Headache may be very very mild

MIGRAINE AURA AND ISCHAEMIC STROKE

Migraine aura is a marker for increased risk of ischemic stroke in young womenAssociated with increased risk of

DiabetesHigh cholesterolHypertensionSmoking

PROGESTOGEN-ONLY CONTRACEPTION

Not associated with any significant alteration in haemostasis Not associated with an increased risk of ischaemic stroke

Tzourio et al BMJ 1995;310:830-3WHO Contraception 1998;57:315-24

Heinemann et al Eur J Contracept Reprod Health Care 1999;4:67-73

CHCS AND ISCHAEMIC STROKE

Prothrombotic effectIncreased risk of ischemic stroke in current users of low dose pills (<50 mcg EE)

RR 1.93 (95% CI = 1.35-2.74)

Avoid additional factors that increase risk

Gillum et al JAMA 2000;284:72-8

UK MEDICAL ELIGIBILITY CRITERIA (UKMEC)

UKMEC 2009 www.fsrh.org

WHAT EFFECTS DO HORMONAL CONTRACEPTIVES HAVE ON MIGRAINE?

OESTROGEN AND MIGRAINE

Oestrogen ‘withdrawal’migraine without aura

‘menstrual’ migrainemigraine in the hormone-free interval of CHCs

High levels of oestrogenmigraine with aura

during CHC usepregnancyHRT

MIGRAINE DURING THE HORMONE-FREE INTERVAL

Natural oestrogen supplements during HFI100mcg patch on last day of pill packetReplace on 4th day of hormone-free intervalRemove on 1st day of next packet

Three day hormone-free interval TricycleContinuous (break with the bleed)

MacGregor EA, Hackshaw A J Fam Plann Reprod Healthcare 2002; 28:27-31

Calhoun A, Ford S Headache 2008;48:1186-1193

Sulak PJ et al Am J Obstet Gynecol 2002;186:1142-9

LaGuardia KD et al Fertil Steril 2005;83:1875-7

SUMMARY

Migraine aura is a marker of increased risk of ischemic strokeContraceptive use of CHCs contraindicated for women with migraine auraCHCs can be beneficial for migraine without aura!

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