Question of the Week # 116

116) A 26 year old woman has dysmenorrhea that has not responded to treatment with NSAIDs. Her past medical history is significant for migraine without aura and takes  Topiramate  for prevention of migraine. Her migraines are well prevented now. She is also sexually active and requests contraception. In view of her dysmenorrhea, OC pills have been recommended to her as it serves to address both the issues of contraception as well as her dysmenorrhea. But she tells you that she once read the package insert in the OC pills and also heard from her friends that she should not use OCPs because she has migraine. Her exam does not reveal any neurological deficits. She does not smoke and leads an active lifestyle. Her B.P  is 110/70. What is your best recommendation to her?
A. Reassure her and start OC Pills
B. Tell her to use condoms alone
C. Start minipill because OC pills may worsen her headache
D. Start OC pills but switch topiramate to valproic acid to prevent her migraines better

2 Responses

  1. Choice A is correct. This patient has migraine without aura, no focal neurological deficits and no additional risk factors for stroke. So, it is recommended to start OC pills as benefits outweigh risks in her case ( i.e; OC pills will improve her dysmenorrhea).
    Several studies have shown that headache occurring in association with OC use tended to improve despite continued OC use. OC pills are contraindicated only if migraines are associated with aura or neurological deficits or if the patient has additional risk factors for a stroke other than OC pill use alone.

    Choice B is incorrect. Condom use is not superior to OC pills in regards to providing effective contraception. This modality also does not benefit her dysmenorrhea.

    Choice C is incorrect. Progesterone only pill will not benefit her dysmenorrhea

    Choice D is incorrect. Patient’s migraine is well controlled on Topiramate. In this setting, switching to another agent in the absence of contraindications or adverse effects is inappropriate.

  2. D

    Topiramate itself is a weak inhibitor of CYP2C19 and induces CYP3A4; a decrease in plasma levels of estrogens and digoxin has been noted during topiramate therapy. This can reduce the effectiveness of oral contraceptives (the pill); use of alternative birth control methods is recommended. Neither intrauterine devices (IUDs) nor Depo-Provera are affected by topiramate.

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