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

15 Responses

  1. B

  2. B

  3. D
    Dr Red please tell the answer.
    Thanks

  4. D

  5. D

  6. can someone clarify? if someone is <35 and no history of aura, then they can continue low dose of the same medication

  7. A)Switch to low dose estrogen pill
    Approach-21 days OCP(Combined)+Start low dose estrogen
    approach 2-Take OCP(Combined) for 28 days for 3-6 months

  8. switch to minipill,

  9. its progesteron which is causing the problem so either we need to discontinue pills or start low dose estrogen in drug free period but if we do so how patient is going to have breakthrough bleeding

    so the best is stop ocp and advise for iucd
    so c is best answer

    need answer from dr red

  10. d) because all the episodes of migraine are in the pill free days that means OCP is helping the migraine in this case..

  11. Headaches are frequently cited for women to discontinue OCP’s, but there is no strong correlation of headaches and OCP’s and there is no evidence that the type of progestin or amount of estrogen will alter headaches, except in women with menstrual migraines! Among migraines, headache may improve, worsen or remain unchanged.

    There’s a catch though– There’s an increased risk of cerebral thromboembolism in women with a history of pseudotumor cerebri or migraines with AURA, neurological problems, here OCP’S will be contraindicated for SURE!

    This patient does not have an aura, so we would see her response to the OCP’s which would be extended duration OCP’s. If it worsens, then you will stop the OCP. If it improves, continue, if it has no effect, continue!

    Peace,
    Mufy 😉

  12. D. Dx is estrogen-withdrawal headache. WHO recommends reducing the hormone-free interval to <7days. Check out: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2938905/

  13. Recap: This woman is experiencing episodes of severe migrane without aura almost exclusively during the pill free week of her OC cycle. She is experiencing estrogen withdrawal migrane. I would use this protocol:
    I would eliminate the placebo pills and replace them with OCP, meaning I will extend the cycle to 84 day of continued hormonal combined pills (7 days short of 3 months). Studies have shown that headaches occurring with OC tend to decrease with continued use of OC. The drop in estrogen during the pill free period is most likely responsible for this woman’s increases frequent of migranes. Option D. When estrogen falls, it triggers a fall in serotonin concentration in the central nervous system, by decreased production and faster elimination, and the resultant decline in serotonergic function causes release of calcitonin gene-related peptides and substance P from trigeminal nerves causing trigeminal nerve pain and cerebrovascular vasodilation. Extending duration of OC pills may do the trick. 84 consecutive hormonal pills followed by 7 days of placebo.
    If migrane still progresses and starts to occur while this woman is on OC pills. Then this suggests that probably estrogen withdrawal is not the culprit as she is using full dose estrogen component in OC Pills and headaches are occurring when she is on these pills. Now my best step would be to switch to low dose estrogen pills during placebo Option A.
    If this doesn’t work, I will switch to minipill which has no estrogen and only progestin. Option B.
    If she develops AURA, I will discontinue/ stop all OCP and do and urgent Head CT. She is at risk of ischemic stroke. Option C.
    Order D -> Order A -> Order B -> Order C
    KEY: pill free periods,
    SUMMARY: Having migrane when pill free – extend pill
    Having migrane on OC pills – low dose estrogen
    worsening migrane – switch to minipill
    AURA – discontinue OCPs, do head CT scan.

    • Please ignore my post above and look at my next post. – Adnan

  14. Recap: This woman is experiencing episodes of severe migrane without aura almost exclusively during the pill free week of her OC cycle. She is experiencing estrogen withdrawal migrane. I would use this protocol:
    I would eliminate the placebo pills and replace them with OCP, meaning I will extend the cycle to 84 day of continued hormonal combined pills (7 days short of 3 months). Studies have shown that headaches occurring with OC tend to decrease with continued use of OC. The drop in estrogen levels during the pill free period is most likely responsible for the migranes. Option D. When estrogen falls, it triggers a fall in serotonin concentration in the central nervous system, by decreased production and faster elimination, and the resultant decline in serotonergic function causes release of calcitonin gene-related peptides and substance P from trigeminal nerves causing trigeminal nerve pain and cerebrovascular vasodilation. Extending duration of OC pills may do the trick. 84 consecutive hormonal pills followed by 7 days of placebo.
    If migrane still progresses in severity and/ or starts to occur while this woman is on OC pills; now I would introduce reduce estrogen component during pill free periods. If headaches still keep getting worse, then I would switch OC pill regimen completely to low dose estrogen pills (Loestrin ) Option A.
    If this doesn’t work, I will switch to minipill which has no estrogen and has only progestin. Option B.
    If she develops AURA, I will discontinue/ stop all OCP and do an urgent Head CT. She is at risk of ischemic stroke. Option C.
    Order D -> Order A -> Order B -> Order C

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