Migraine and the contraceptive pill
We look at the effect of hormones in the contraceptive pill on migraine
The role of hormones and migraine
Migraines are more common in women than in men and the difference is more common in the reproductive years. The main reason for this is the role of the female sex hormone which implicates the menstrual cycle as a significant migraine trigger for women.
Sex hormones, oestrogen and progesterone, and the physical and chemical processes that go towards producing them, all have a widespread effect on your body and as the contraceptive pill is made up of similar hormones there will be an effect on your migraines.
Some women are more sensitive to the fluctuations within the menstrual cycle. Studies suggest, for example, that migraine can be triggered by a drop in your oestrogen levels such as those which naturally occur in the time just before your period and the result of falling oestrogen levels in the later phase of the menstrual cycle.
Hormones and the contraceptive pill
It is important to mention that headaches are a common side effect of taking oral contraceptives and in that case usually improve over time. They can be affected by the dose and type of hormone in the pill. Some women find that their headaches and migraines improve when they start the pill; others notice that their headaches and migraine get worse. Studies suggest that headaches are less likely to occur with the lowest dose pills (20 micrograms of oestrogen) containing newer types of progestogens but this is not the same for everyone. It is important to find the pill that suits you best.
Types of oral contraceptives
It is important to understand the combinations of oral contraceptives available, to establish which is the best for you and the type of migraine you have.
You should ensure your GP or family planning advisor understands whether you have migraine with or without aura before prescribing the pill.
There are two types of oral contraceptives:
- Combined oral contraceptives
- Progestogen-only pills.
Combined oral contraceptives
This type of contraceptive pill is made up of a combination of a particular type of oestrogen, called ethinyloestradiol, and a particular type of progesterone, called progestogen. The Pill was introduced over 40 years ago, and the amount of hormones is now much lower than in the past . This has meant that unwanted effects like headaches and migraines, are much less likely to occur when they take the Pill. However, for many women their migraine attacks become more severe or frequent during the week they do not take the Pill. This is because the hormone levels drop at this time. The drop in oestrogen can trigger the migraine.
What to do
There are several ways to prevent headache or migraine that occurs only during the week that you don’t take the Pill:
- Consider changing to a different type of Pill with a different dose of ethinyloestradiol and/or a different type of progestogen.
- You may find that by taking the Pill continuously for at least 3 cycles followed by a 4 to 7 day break may help. This keeps the levels of oestrogen constant whilst you are taking the 3 packets. You should have less withdrawal bleeds per year and therefore fewer migraines.
- You may wish to consider taking the Pill continuously and never take a break.
Taking the Pill continuously
Dr Anne MacGregor discusses this in her books ‘Migraine and Women’ and ‘Migraine and Other Headaches’. She explains that taking the Pill continuously can stop migraines. However, because there is no controlled withdrawal bleed, unpredictable breakthrough bleeding may occur.
In Dr MacGregor’s words: ‘there is little evidence that the monthly breaks from the pill are associated with any added health benefits and that the benefits of reduced menstrual problems and increased efficacy are clear’.
The combined contraceptive pill and the risk of stroke
If you get migraine with aura you should not take the combined oral contraceptive Pill. This is because the combined pill is associated with a very small increased risk of ischaemic stroke. This risk increases when the Pill is taken by women who have additional risks for stroke, such as smoking and migraine with aura. Statistics show that the risk is extremely small but never-the-less it is still a risk, which can be avoided. The risk from the Pill is due to ethinyloestradiol, and not progestogen. So progestogen-only contraceptives are a safer alternative. Some of these are more effective contraceptives than the combined Pill.
You may consider taking this form of contraception if you are unable to take the combined pill. Although this method suits many women, others find that erratic bleeding is a problem. This can, in turn, lead to more headaches.
Taking the Pill and the risk of stroke
For most women the Pill is a safe form of contraception. However, women who have high blood pressure and /or smoke heavily are not advised to take the pill as they are at risk of developing a stroke and this is increased further by taking the pill. If you normally have migraine without aura and then you start to experience aura after starting the pill you should stop taking the pill and change to another form of contraception.
Migraine with aura and the Pill
Studies have shown that there is an association with migraine with aura and ischaemic stroke. An ischaemic stroke occurs as a result of a reduction or loss of blood supply to part of the brain. As was stated earlier, this means that if you have migraine with aura you are at more risk of experiencing a stroke if you take the combined oral contraceptive pill. The risks are extremely small but nevertheless the risk is there and cannot be ignored. You can still use progestogen-only methods.
Other methods of contraception
There are a range of progestogen-only methods of contraception around that are a safer alternative for women who cannot take combined hormonal contraceptives. Some of these, such as implants, injectable progestogens and one type of progestogen-only pill containing the progestogen desogestrel, act in the same way as the combined hormonal contraceptives in that they inhibit ovulation. You should discuss this with your family planning advisor. The list includes:
- Implants – lasts for three years
- Injection – lasts for three months
- Progestogen – only pill – taken daily without a break
- Intrauterine system – inserted into the womb and last for five years
Non hormonal methods of contraception
If you decide to switch to a non hormonal form of contraception there is a range of methods to choose from. You should consult your GP or family planning advisor. You may choose the coil (copper intrauterine device), however this may make migraines worse as periods become heavier. Condoms and diaphragms have no effect on the hormonal pattern.
Emergency contraception and migraine
Emergency hormonal contraception contains only the hormone progesterone. It can be used for emergency contraception to prevent pregnancy after sexual intercourse. This is usually taken within 72 hours after intercourse, but is most effective if taken within 12 hours.
Taking oral contraception to control migraine
If your migraine is associated with premenstrual syndrome (PMS) you may find that the combined oral contraceptive pill or the injectable contraceptive can help reduce migraine at this time in your cycle. As these hormones switch off the normal menstrual cycle the natural fall in oestrogen does not occur so premenstrual migraine should be alleviated or reduced.
- Family Planning Association www.fpa.org.uk
- National Association for Premenstrual Syndrome www.pms.org.uk
- Women’s Health Concern www.womens-health-concern.org
MacGregor. A Understanding Migraine and Other Headaches Family Doctor publications in association with The British Medical Association 2006
MacGregor. A Migraine in Women Revised Edition Martin Dunitz 2003