Current Series: New Paradigms: Preventive Treatment for Chronic Migraine

Stephen Silberstein, MD: Let’s move on a bit. What’s the role of hormonal therapy in patients who have migraine with their period? Deb?

Deborah Friedman, MD, MPH: There are a lot of different ways to approach menstrual migraine, and many women who have migraine find that they have migraines that are a lot worse, and a lot more severe around the time of their periods, even though they may have them at other times of the month. Headache specialists, to some extent, approach this differently than gynecologists do. In the headache world, I think we’re more likely to either use a short-term mini prophylaxis, such as a long-acting triptan, or maybe transiently increase the dose of whatever oral preventive the person is already taking. But sometimes we do end up using hormonal therapy, and an option is using a very low-dose estrogen oral contraceptive, and using it continuously for 3 to 6 months, trying to suppress ovulation and that drop in estrogen right before their period starts. Other people will use an estrogen patch just around the time of a menstrual cycle. There are potentially hormonal therapies that can be employed.

Stephen Silberstein, MD: What about the use of estrogen in somebody with migraine with aura?

Stephanie J. Nahas, MD, MSEd, FAHS, FAAN: I was just going to volunteer that little bugaboo if you didn’t bring it up, because you know this is a hurdle that I will face. More often than not, I’ll have a woman with migraine with aura come in to me and say, “My gynecologist won’t give me a birth control pill until you say it’s OK.” They have a much different philosophy on this. Their guidelines differ from some of the other medical societies, and so I have to say, “Well, I can’t tell you that it’s absolutely OK; nothing is without risk.” So let me break down the numbers.

There’s a baseline risk that you could have a stroke if you didn’t have migraine, or any medical problem; it’s really very low. If you have migraine, it goes up a little. Migraine with aura, up a little bit more. Now you add an oral contraceptive, which we know carries a risk for stroke or other thrombotic events. It keeps going up and in fact, it multiplies. But the number you’re left with is still pretty low. Maybe 30 to 40 per 100,000 for a healthy young woman. When they hear those numbers, they’re more reassured that the risk they’re taking is worth the benefit that they may get. It’s all about risk/benefit, right?

Stephen Silberstein, MD: Agreed. Any other comments?

Andrew Blumenfeld, MD: Well, I find that patients who are entering the perimenopausal period tend to do particularly badly with a lot of fluctuations in estrogen, and those patients can be very hard to manage. I find that group actually does best with an estrogen supplement, but they’re also a very high-risk group for supplementation.

Stephen Silberstein, MD: My bias, and there are actually studies to prove this—an estrogen patch, transdermal estrogen, perimenopausal—is safe, effective, and stabilizes the situation. I would also point out that the controversy a couple years ago of not replacing hormones in perimenopause was false. The analysis clearly showed that the people did worse, but they didn’t account for the fact that the estrogen was started 6 to 10 years after menopause. When they reanalyzed their data, they showed that immediate replacement with estrogens was beneficial. That’s why you have to be very careful when you read all these studies. So my bias is, in perimenopause, it makes sense to use estrogen replacement by patch.

Deborah Friedman, MD, MPH: It’s also really important to keep in mind that a lot of the studies that were done, that the American College of Obstetricians and Gynecologists has based their guidelines on, were based on really old data using oral contraceptives that had 50 mcg of ethinyl estradiol in them, which had a very high risk for thrombosis and stroke. The oral contraceptives that we use now are completely different, and I think it’s just not right to be very dogmatic about making statements based on the data.

Stephen Silberstein, MD: You’re absolutely 100% correct, and you read my mind. The International Headache Society one time created guidelines for hormonal contraception, and I’ll remember that to my dying day. I flew to Paris, met all day, changed in the locker room and left the next morning. But we created guidelines. They haven’t been updated for a long time.