Experts offer advice on hormonal contraceptive use in women with migraine

By Lorraine L. Janeczko

NEW YORK (Reuters Health) - Hormonal contraceptives may increase the risk of stroke in young women with migraine, and providers can guide their patients toward the safest birth control options, according to a consensus statement by the European Headache Federation and the European Society of Contraception and Reproductive Health.

"While migraine is very common and hormonal contraceptive use is quite common, ischemic stroke risk is rather low in young women," lead author Dr. Simona Sacco of the University of L’Aquila, in Italy, told Reuters Health by email. "But stroke is a serious disease that may be fatal or disabling, and hormonal contraceptive use with migraine is associated with increased risk of stroke."

"The risk may be avoided by simply choosing the safest contraception from the many options that exist, taking migraine status into account," she advised.

Dr. Sacco and her fellow panel members searched standard medical databases for studies investigating migraine, ischemic stroke, and hormonal contraceptive use. They ultimately used information from 48 reviews, guidelines, letters, and expert commentaries; three meta-analyses; and 12 observational studies to guide their work.

As reported online October 30 in the Journal of Headache and Pain, the experts settled on 13 consensus statements, including four identified as “strong”:

- Before prescribing hormonal contraceptives, evaluate women for the presence and frequency of migraine, migraine subtype (with or without aura), and conventional vascular risk factors.

- Use a dedicated, easy-to-use tool to diagnose migraine and its subtypes.

- Consider the type of hormonal contraception being sought, as well as the influence of that particular type of contraception on ischemic stroke risk.

- For contraceptive-seeking women who have migraine with aura, non-hormonal contraception or progestogen-only contraceptives are preferred.

"Many questions on this topic remain unanswered, and I hope the document prompts further research," Dr. Sacco said. "We need experimental studies to understand the mechanisms linking migraine, stroke, and contraceptives; and we need clinical studies to better understand the risks linked to the various contraceptive options available."

Dr. Robert Brown Jr. of the Mayo Clinic in Rochester, Minnesota, who was not involved in the study, said in an email that the consensus document summarizes the available data well: "The paper appropriately emphasizes that migraine subtype and frequency, and the presence of other risk factors such as cigarette smoking, hypertension, obesity, history of cardiovascular disease, among others, should be considered in these decisions."

"For most of the recommendations, the overall quality of the available evidence is described (as) ‘low,’ and additional research is necessary. Until those data are available, however, comprehensive consensus documents such as this can help guide patient care and define gaps in the available literature," he noted.

Dr. Jason Bell of the University of Michigan in Ann Arbor, also not involved in the study, said in an email, "Overall, I think this was a well-written manuscript and a nice summation of the known literature regarding migraine and combined hormonal contraceptives. That said, the authors really do not expand on the knowledge that is known and already being applied in clinical medicine."

He said the panel's suggestion that the most important clinical issue is whether or not the woman has aura, and the inclusion of degrees of strength of evidence in the summary statements are helpful, but that the results need to be validated in larger studies.

Dr. Bell advises that for now, clinicians "continue to use the Medical Eligibility Criteria from either the U.S. Centers for Disease Control and Prevention (http://bit.ly/2iUysvg) or the World Health Organization (http://bit.ly/2qGC72v) to help screen their patients and ensure that they receive the safest and most effective contraception."

SOURCE: http://bit.ly/2igTMLn

J Headache Pain 2017.

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