Question of the Week # 118

118) A 30-year-old woman has been using oral contraceptive pillls, combination type for past 8 yrs. However, she also has a history of migraines. Lately, she has been experiencing an average of 14 episodes of severe migraine without aura yearly. Careful evaluation of her headache calender reveals that most of them occur exclusively during the pill-free week of her OC regimen. She has no history of smoking. She has never had DVT or family hx of thrombophilia. Her physical exam is normal without any neurological deficits. Next step in management ?
A. Switch to low dose estrogen pills
B. Switch to minipill
C. Discontinue OC pills
D. Start extended duration OC pills like seasonale

6 Responses

  1. c.

  2. D. Pt has no aura, history of clot disorders and migrane occurs exclusively during placebo period. Extends OC has been proven to be of benefit as longs as there’s no additional risk.

  3. C: stop ocp and offer an alternative IUD (IUS) since its success rate is 99% x 10 yrs for copper and 98% x 5 yrs for “Marina” that is levonorgestrel however since this pt’s migrains are related to hormonal therapy, i would then choose copper.

  4. A. pt has no aura but estrogen can sometimes worsen migraine so switching to low dose can work

  5. I agree the answer is A : Switch to low dose estrogen.

    Have the case described Migraine with aura or other focal neurologic changes like hemiperesis or dysphasia for more than one hour, DVT ,and / or smoking the answer would have been STOP OCP immediately and switch to the mini pill. low dose estrogen in this group have shown to INCREASE the risk of ischemic stroke.

  6. D….
    The belief that oral contraceptives will worsen migraine headaches is common. However, the studies of oral contraceptives described above show that some individuals may benefit from extended-duration therapy. Therefore, health care professionals should assess the risks versus benefits when prescribing these agents to patients with migraine headaches. The patient’s medical history, type of migraine headache, and contraindications to oral contraceptives need to be evaluated before starting therapy. However, women who have failed traditional nonhormonal migraine therapies and suffer from uncontrolled menstrual migraines may find that their symptoms are improved by oral contraceptives. For example, a woman who suffers menstrual migraines 12 times/year may experience fewer days of disability if her headaches occur only 4-6 times/year. In addition, appropriately selected women with well-documented, true menstrual migraines are eligible for prophylactic therapies involving hormonal manipulation, even if they have not failed other prophylactic therapies. This recommendation, which is based on the literature and the contemporary shift from a stepped-care to a stratified-care approach, may shorten the time needed to achieve migraine control

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