Migraine with Aura Dr Jill Zelin for Prof Anne MacGregor Barts Health NHS Trust & Barts and the London School of Medicine and Dentistry UK.PH.GM.X d 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?

normal I premonitory II aura III headache IV resolution V recovery normal headache food craving tired/yawning heightened perception anorexia/nausea/vomiting malaise/ lethargy sensitive to light/sound heightened sense of smell vomiting sleep limited food tolerance tired diuresis poor concentration difficulty focusing fluid retention hungover drugs 2-24 hrs When does a migraine start? Blau JN Lancet 1992;339: <1 hr4-72 hrs2-12 hrs 2-24 hrs

Premonitory visual symptoms premonitory headache Giffin N et al Neurology 2003;60: hours VAS rating of state of health 28% reported blurred vision 49% reported light sensitivity

Migraine aura 99% visual Scintillating scotoma Important points – Relationship to headache Starts before Resolves before – Duration Lasts less than 60 minutes - typically mins – Symptoms are specific

Diagnosis Do you ever have visual disturbances – Starting 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 women Associated with increased risk of – Diabetes – High cholesterol – Hypertension – Smoking

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;310:830-3 WHO Contraception 1998;57: Heinemann et al Eur J Contracept Reprod Health Care 1999;4:67-73

CHCs and ischaemic stroke Prothrombotic effect Increased risk of ischemic stroke in current users of low dose pills (<50 mcg EE) – RR 1.93 (95% CI = ) Avoid additional factors that increase risk Gillum et al JAMA 2000;284:72-8

UK medical eligibility criteria (UKMEC) UKMEC

What effects do hormonal contraceptives have on migraine?

Oestrogen and migraine Oestrogen ‘withdrawal’ – migraine without aura ‘menstrual’ migraine migraine in the hormone-free interval of CHCs High levels of oestrogen – migraine with aura during CHC use pregnancy HRT

Migraine during the hormone-free interval Natural oestrogen supplements during HFI – 100mcg patch on last day of pill packet – Replace on 4th day of hormone-free interval – Remove on 1st day of next packet Three day hormone-free interval Tricycle Continuous (break with the bleed) MacGregor EA, Hackshaw A J Fam Plann Reprod Healthcare 2002; 28:27-31 Calhoun A, Ford S Headache 2008;48: Sulak PJ et al Am J Obstet Gynecol 2002;186: LaGuardia KD et al Fertil Steril 2005;83:1875-7

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