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The benefits of contraceptives in the management of menstrual migraine

A MacGregor

The City of London Migraine Clinic, London, United Kingdom

More than 50% of women with migraine, both in the general population and presenting to specialist clinics, report an association between migraine and menstruation. There is evidence that menstrual attacks of migraine are associated, at least in some women, with falling levels or 'withdrawal' of estrogen during the late luteal phase of the menstrual cycle. Suppression of cyclical ovarian activity with combined hormonal contraception (CHC) is an effective theoretical strategy but in practice migraine can be triggered by estrogen 'withdrawal' during the hormone-free interval. Extending the active interval and shortening the hormone-free interval is becoming increasingly popular [1]. However, no double-blind, placebo-controlled trials, or even open-label trials, of this strategy have been undertaken for this indication. Progestogen-only contraception has the advantage of continuous administration and, unlike CHCs is not even contraindicated for women with aura [2]. But standard contraceptive oral progestogens do not consistently inhibit ovulation and the resultant disrupted menstrual cycle can be associated with increased migraine frequency and severity. In contrast, higher doses of standard oral progestogens, sufficient to inhibit ovulation, can prevent menstrual migraine [3]. On this basis Cerazette®, a licensed anovulatory progestogen-only pill may have advantages over standard progestogen-only pills for women with migraine. Interim results from an ongoing study show benefit and formal trials with Cerazette® for the management of menstrual migraine are indicated.

References

  1. Sulak PJ, Carl J, Gopalakrishnan I, Coffee A, Kuehl TJ. Otcomes of extended oral contraceptive regimens with a shortened hormone-free interval to manage breakthrough bleeding. Contraception 2004;70(4):281-7.

  2. World Health Organization. Improving access to quality care in family planning. Medical eligibility criteria for initiating and continuing use of contraceptive methods. Third ed. Geneva:WHO,2004.

  3. Davies P, Fursdon-Davies C, Rees M. Progestogens for menstrual migraine. J Br Men Soc 2003;9(3):134.