Birth control and migraines:
What's the link?
Prevalence of migraines
The prevalence of migraines in people between 20-50 years is around 14.2 %. Incidence is higher in women and even higher in women of reproductive age.
Symptoms of Migraine & What is an aura-'sensing' a migraine?
Migraine is a benign and recurring syndrome of headache, nausea, vomiting, and other neurological symptoms such as aversion to light and sound. It happens on one half of the head and the patient experiences a pulsating or throbbing kind of pain that increases with activity. Each attack can last for 4 to 72 hours if untreated, or treated unsuccessfully and cannot be attributed to any other cause.
Aura is the complex set of neurological symptoms that occurs a while before the onset of a headache and almost completely goes away when the patient starts having the headache. Simply put, aura is the set of symptoms you get right before the migraine giving you a heads up that it is coming. All symptoms last for 5 minutes to an hour. An aura may consist of one of the following:
- Fully reversible visual symptoms such as flickering, spots or lines in the field of vision or loss of vision.
- Pins and needles sensations or numbness anywhere in the body.
- Any speech disturbance.
Why COC pills and migraines don’t mix
- Studies have found that migraine patients who are also combination pill (COC) users are at twice the risk of an ischemic stroke as compared to non-users.
- The risk goes up to as high as 7 times if they are also smokers.
- The higher the concentration of estrogen in your pill, the higher are your odds for a stroke. In contrast, progesterone concentrations do not affect this risk in any way.
The American College of Obstetrics and Gynecology (ACOG) discourages the use of combined oral contraceptives in migraine patients with aura. It is important to keep in mind that other risk factors such as increased weight, poor control over sugar or lipids may also compound your risk.
What if I get a premenstrual migraine?
Premenstrual migraines are part of a larger set called estrogen withdrawal headaches. Women experience these due to a fall in estrogen levels in the luteal phase (after day 21) of the menstrual cycle and due to increased pain producing substances or prostaglandins in the body.
While OC pills should help with these kinds of migraines, it is recommended that women try conventional painkillers and anti-migraine medication such as triptans. If that fails, OC Pills may be considered.
Options for migraine patients
Migraine with aura
- Migraine with aura is associated with a small risk of ischemic stroke which means the loss of blood supply to a part of your brain if simultaneously taking OC pills. Thus, avoid a combination pill at all costs.
- Options patients may consider are:
- Progesterone only pills/ minipills – take daily
- Depo-provera or Injection – lasts three months
- Hormonal IUD such as Mirena – lasts 3-5 years
- Implant – lasts three years
- Non hormonal methods such as barrier contraception and non medicated IUD
Migraine without aura
- Apart from all the options mentioned above, in patients having migraine without an aura, they can also consider using combined oral pills, that is, pills that contain both estrogen and progesterone.
- The usage of OC pills must be allowed only after ruling out any additional risk factors such as smoking, history of stroke in the family and age over 35.
- However the schedule for taking these pills can be altered to prevent migraines.
- Patients can either:
- Take the pills continuously for three cycles and take a 4-7 day break OR
- Take the pills continuously without a break. The fall of the hormone estrogen is said to cause the migraine. In doing so, we avoid drop in estrogen levels and prevent a migraine attack.
- If patients that initially didn’t have an aura with migraine start developing an aura after starting the pill, it is best to discontinue it.
Emergency contraception in migraines
Since emergency contraception is free of estrogen, it is safe to take for migraine patients.
Migraines related to PMS
Patients having premenstrual migraines may benefit from a trial of oral contraceptives or the injection method. Both these options prevent a normal menstrual cycle and the accompanying fall in estrogen that causes migraine.
I have recently started an OC pill and have developed a headache. Is it a migraine? Should I discontinue?
OC pills are generally associated with a headache in the first three cycles. The headaches resolve over time. It is important to differentiate that headache from the key features of a migraine mentioned above. If you feel you have a migraine, it is best to take a healthcare provider’s opinion.
Consult a healthcare provider immediately if you experience severe or worsening headaches and any alarming symptoms.