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Migraine w/ aura + OCP


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Hello,

 

I am on a rotation and was wondering if any seasoned PA, jmj or other, can give their 2 cents on this.

 

Pt in her early/mid 20's presents requesting OCP.  She has had migraines with aura since puberty.  Migraines occur ~4 times every week.  They are significantly worse and more common surrounding menstruation.  She has failed several medications and is in the process of weening off them, and is discussing botox injections with her neurologist.  

 

She talked to her neurologist about starting on an OCP.  Her neurologist discussed this with her, and they agreed that so long as she understood the risks, it would be okay.  I did a little research on this, and from what I could tell, this is what it boils down to:

- Migraine w/ aura is a 6-fold increase for TIA or CVA

- OCP is a 2-fold increase for TIA or CVA

- Thus, they are contraindicated as an 8-fold risk is considered too high

 

We discussed in detail these risks in our office.  She was told by her neurologist to get an OCP that does contain estrogen (eg not depo or anything else), because the estrogen may help with the migraines.  She met no other risk factors for OCP use and had a more or less clean slate regarding family history.  She was in good shape and healthy.

 

Is giving her the OCP the right thing to do?  Who is then responsible to follow up on possible change in aura, the GYN or neurologist?  Would this be appropriate in a pt > 35 years old?  Should we have pushed for her to receive a progesterine only OCP?  She was intelligent and understood the risks and will be followed.  Any insight is appreciated.  Most the articles I read painted a picture that most PA/MD/DOs will not write for OCP in this situation, however after discussing with a friend who is an intern, it is apparently a fairly common practice in real life.

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Hi:) I am a pre-PA applying to schools at the moment so you don't have to take my advice to heart since I don't have a license yet BUT I am in my young/mid twenties and have experienced Ora migraines since before puberty and they increase greatly with menstruation. I have managed them with simple ibuprofen but recently I decided to go to a neurologist since I am concerned about my excessive use of Advil on my stomach. He immediately associated my problem with estrogen and said that my OCP was doubling my chance of a stroke and triggering the migraines further. He seemed to be certain based on experience with other young women like myself. He basically sent me back to my GYN to discuss alternative contraceptive and offered me other pain meds to treat them at onset. I haven't followed through with this advice yet but I thought I would share his insight with you since he basically agrees with your reservations and concerns. I think maybe the progestin only pill would be helpful if she isn't using it for birth control since they are a little less effective in that department.

Again, this is completely from personal experience not expert advice. I like reading some medical cases that interest me on the forum and this one particularly struck interest to me!

Best of luck!

 

 

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Thanks for the input.  Let me know what your neurologist says, and if you think it makes a difference at all.  

 

From my research it sounds pretty individualized, with some pts migraines getting better, worse, or no change; however the literary consensus still seems to be that this is contraindicated nevertheless.  I suppose if estrogen is imbalanced in the first place, the OCP may regulate it and potentially help with the migraines.  This particular pt reported having regular menstrual cycles, however.  Unfortunately our education on migraines and mesntruation was limited to knowing the association between them and that they can be a trigger for some pts, and that OCP + migraine w/ aura is CI.

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Hello,

 

I am on a rotation and was wondering if any seasoned PA, jmj or other, can give their 2 cents on this.

 

Pt in her early/mid 20's presents requesting OCP.  She has had migraines with aura since puberty.  Migraines occur ~4 times every week.  They are significantly worse and more common surrounding menstruation.  She has failed several medications and is in the process of weening off them, and is discussing botox injections with her neurologist.  

 

She talked to her neurologist about starting on an OCP.  Her neurologist discussed this with her, and they agreed that so long as she understood the risks, it would be okay.  I did a little research on this, and from what I could tell, this is what it boils down to:

- Migraine w/ aura is a 6-fold increase for TIA or CVA

- OCP is a 2-fold increase for TIA or CVA

- Thus, they are contraindicated as an 8-fold risk is considered too high

 

We discussed in detail these risks in our office.  She was told by her neurologist to get an OCP that does contain estrogen (eg not depo or anything else), because the estrogen may help with the migraines.  She met no other risk factors for OCP use and had a more or less clean slate regarding family history.  She was in good shape and healthy.

 

Is giving her the OCP the right thing to do?  Who is then responsible to follow up on possible change in aura, the GYN or neurologist?  Would this be appropriate in a pt > 35 years old?  Should we have pushed for her to receive a progesterine only OCP?  She was intelligent and understood the risks and will be followed.  Any insight is appreciated.  Most the articles I read painted a picture that most PA/MD/DOs will not write for OCP in this situation, however after discussing with a friend who is an intern, it is apparently a fairly common practice in real life.

 

 

Really good question.  The risk (as you have said) for migraine with aura for women <40 years old is between 3.8-8.2 times the normal controls (depending on the study).   Here is a quote from our June issue of Headache. By the way a great article that I wish I could post, but see if you can get your hands on it. I can fax it if you need it.: (Headache 2013;53:247-276)

 

Migraine with aura is also associated with a
two fold increased risk of ischemic stroke compared
with women with migraine without aura or no
migraine.There is evidence to suggest that the combination
of these and other risk factors, including use of
combined hormonal contraceptives, is multiplicative
rather than additive. Given the availability of more
effective methods of contraception that are not associated
with increased risk of ischemic stroke, it is difficult
to justify exposing women with migraine with aura to
unnecessary and avoidable risks solely for contraceptive
purposes. However, when a contraceptive method
is used for a medical indication such as endometriosis
or polycystic ovary syndrome, the risk/benefit ratio differs and may well shift toward the benefits of combined
hormonal contraceptive use outweighing risks.
This should be considered on a case-by-case basis.
 
With that said, estrogen containing OCCs are more likely to worsen migraine than help. Occasionally they will help (if taken continuously)   menstrual migraine but at what cost?  I bet I can name a few preventative treatments she has not tried that would be safer.
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