Migraine with Aura
Dr Jill Zelin for
Prof Anne MacGregor
Barts Health NHS Trust &
Barts and the London School of Medicine and Dentistry
www.annemacgregor.com
UK.PH.GM.X.2012.042d 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
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?
Positive predictive value for migraine diagnosis:
2 positive answers – PPV = 93%
3 positive answers - PPV = 98%
Lipton et al Neurology 2003;61:375-82
Migraine
Migraine without aura
• 70-80% attacks
Migraine with aura
• 20-30% attacks
• 1% without headache
Is it aura?
When does a migraine start?
headache
anorexia/nausea/vomiting
malaise/ lethargy
food craving
tired/yawning
sensitive to light/sound
vomiting
sleep
drugs
heightened sense of smell
heightened
perception
limited food
tolerance
tired
hungover
difficulty focusing
diuresis
poor concentration
fluid retention
normal
I
premonitory
2-24 hrs
II
aura
<1 hr
III
headache
4-72 hrs
IV
resolution
V
recovery
2-12 hrs
2-24 hrs
normal
Blau JN Lancet 1992;339:1202-7
Premonitory visual symptoms
VAS rating of state of health
100
28% reported blurred vision
49% reported light sensitivity
80
premonitory
60
headache
40
20
0
hours
-150
-100
-50
0
50
100
Giffin N et al Neurology 2003;60:935-40
Migraine aura
• 99% visual
• Scintillating scotoma
• Important points
– Relationship to
headache
• Starts before
• Resolves before
– Duration
• Lasts less than 60 minutes
- typically 20-30 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;57:315-24
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 = 1.35-2.74)
• Avoid additional factors that increase risk
Gillum et al JAMA 2000;284:72-8
UK medical eligibility criteria (UKMEC)
UKMEC 2009 www.fsrh.org
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;48:1186-1193
Sulak PJ et al Am J Obstet Gynecol 2002;186:1142-9
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!
www.bash.org.uk