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Migraine with Aura

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?

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Migraine with Aura

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  1. 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

  2. Overview What is migraine? What are the risks of hormonal contraception in women with migraine? What are the effects of hormonal contraceptives on migraine?

  3. Do you have the following with your headaches? Lipton et al Neurology 2003;61:375-82 • 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?

  4. Do you have the following with your headaches? Positive predictive value for migraine diagnosis: 2 positive answers – PPV = 93% 3 positive answers - PPV = 98% Lipton et al Neurology 2003;61:375-82 • 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?

  5. Migraine Migraine without aura Migraine with aura • 20-30% attacks • 1% without headache • 70-80% attacks

  6. Is it aura?

  7. When does a migraine start? headache vomiting anorexia/nausea/vomiting limited food tolerance sleep malaise/ lethargy food craving tired/yawning drugs sensitive to light/sound tired heightened sense of smell hungover heightened perception difficulty focusing diuresis poor concentration fluid retention normal I premonitory II aura III headache IV resolution V recovery normal 2-24 hrs 2-24 hrs <1 hr 4-72 hrs 2-12 hrs Blau JN Lancet 1992;339:1202-7

  8. Premonitory visual symptoms 100 28% reported blurred vision 49% reported light sensitivity 80 premonitory 60 VAS rating of state of health headache 40 20 0 hours 50 100 -150 -100 0 -50 Giffin N et al Neurology 2003;60:935-40

  9. 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

  10. Diagnosis • *Headache may be very very mild • Do you ever have visual disturbances • Starting before the headache?* • Lasting up to one hour? • Resolving before the headache?*

  11. 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

  12. Progestogen-only contraception 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 Not associated with any significant alteration in haemostasis Not associated with an increased risk of ischaemic stroke

  13. CHCs and ischaemic stroke Gillum et al JAMA 2000;284:72-8 • 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

  14. UK medical eligibility criteria (UKMEC) UKMEC 2009 www.fsrh.org

  15. What effects do hormonal contraceptives have on migraine?

  16. 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

  17. Migraine during the hormone-free interval 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 • 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)

  18. 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!

  19. www.bash.org.uk

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