Estrogen: Friend or Foe for Women with Migraine?

As a physician practicing women’s health for many years, I am tired of the “bad rap” that estrogen has received in the media in recent years. I am also dismayed by the negative attitude of many physician colleagues, including gynecologists, who are hesitant to treat women migraine patients with estrogen including estrogen-containing birth control pills. While there may be a very slight increase risk of stroke in migraine patients compared to the general population, that risk is very small and often blown out of proportion. The theoretical concern of increasing stroke risk by putting a female migraine patient on estrogen needs to be balanced against the many potential benefits of estrogen for women.

Benefits of estrogen-containing contraception are many and include:

  1. Prevention of disabling menstrual migraines if taken continuously, thereby preventing the drop in estrogen that is the most common trigger for menstrual migraine
  2. Relief of premenstrual symptoms including mood changes, bloating, and cramping. Some birth control pills are FDA approved for Premenstrual Dysphoric Disorder (PMDD) such as Yaz (now available as a generic). PMDD is a common co-morbid condition with migraine.
  3. Relief of painful menstrual cramps, heavy periods, irregular periods
  4. Relief of acne
  5. Birth control that is highly effective
  6. Treatment of endometriosis
  7. Relief of perimenopausal symptoms including hot flashes, night sweats, insomnia and irregular menses that characterized this time in women’s life

The amount of estrogen in birth control pills used to be as high as 80 micrograms (mcg) of ethinyl estradiol. Current dosages are much lower and are typically 20-35 mcg of ethinyl estradiol (EE). Therefore, studies showing risks of birth control pills need to be looked at in terms of the dose of estrogen being taken as well as the specific product being studied.

When deciding on the risk versus the benefit of prescribing an estrogen-containing birth control pill for a woman with migraine I feel that the following risk factors need to be looked at:

  1. Smoking
  2. Uncontrolled High Blood Pressure
  3. Personal or Family History of Clotting Disorders
  4. Obesity
  5. High Cholesterol

If these risk factors are not present then I feel that most women with migraine can safely be allowed to take an estrogen-containing birth control pill. This is especially important if they need birth control. Given that 50% of pregnancies are not planned and that migraine peaks in women of child-bearing years, then the issue of contraception is critical.

Most health care providers are not comfortable with any form of estrogen in women who have migraine with aura. In my opinion, women with aura should not all be clumped together. There is a big difference in women who have occasional aura and no other risk factors for stroke versus a woman with frequent aura and other risk factors. I have many women who rarely have aura, have no other risk factors for stroke, and have a strong desire to be on an estrogen-containing birth control pill for either birth control or for another medical reason such as to control their painful and/or heavy periods. I usually will allow these women to go on a birth control pill like Yaz or Yasmin and then carefully follow them. If they report an increase in aura or migraine then I re-evaluate our plan and may take them off estrogen. The majority do fine!

Estrogen: friend or foe of the female migraineurs? In most cases, I vote for FRIEND! What do you think?

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