Reproduction & Migraine
Contraception
Headaches are a common problem in women starting the combined pill but these often settle after the first few cycles. Migraine often improves on the pill, although attacks may occur during the pill-free week, just like menstrual migraine. Some women notice that migraine becomes more frequent or severe. If this happens, speak to your doctor, as you may need to use a different method of contraception. Women who have migraine with aura (classical migraine) should not use the combined pill as the combination can increase the risk of stroke. Although this risk remains very small, because it is greater than the risk of stroke associated with pregnancy, it is generally felt that other methods of contraception should be used. Since the risk of stroke is associated with the synthetic oestrogen in the combined pill, safer alternatives include all progestogen-only methods such as the progestogen-only pill, Depo-Provera and the Mirena intrauterine system.
Pregnancy and breastfeeding
Studies suggest that migraine improves in 60 and 70 per cent of women during the latter part of pregnancy, although attacks often worsen in the first few months. Women, who have attacks of migraine without aura before becoming pregnant, particularly if they have noticed a link between migraine and menstruation, are most likely to notice a respite from migraine during pregnancy. This typically continues during breastfeeding until periods return. But not every woman with migraine without aura improves during pregnancy – around 16 per cent continue to have attacks. Also, if migraine starts for the first time during pregnancy, it is likely to be with aura.
Of most importance is the fact that there is no evidence that migraine, either with or without aura, has any effect on the outcome of pregnancy or on the baby’s growth and development.
What can you do to help yourself?
Many pregnant women favour non-drug methods of management while they are pregnant, particularly once they are aware that migraine is likely to improve.
Early pregnancy symptoms can aggravate migraine. Pregnancy sickness, particularly if severe, can reduce food and fluid intake resulting in low blood sugar and dehydration. Try to eat small, frequent carbohydrate snacks and drink plenty of fluids. Adequate rest is important to counter tiredness. Other preventative measures that can safely be tried include acupuncture, biofeedback, yoga, massage and relaxation techniques.
How can the doctor help?
Few drugs have been tested for safety in pregnancy and during breastfeeding because of the obvious concerns. This lack of data means that manufacturers do not generally recommend the use of any drug in pregnancy but this does not mean that they cannot be used. Drugs should only be considered if the potential benefits outweigh the potential risks. Many drugs are most dangerous to the pregnancy during the first three months, often before a woman knows she is pregnant. In order to find out the effects of drugs, most manufacturers keep records of reports of drug use during pregnancy and follow the outcome. These reports suggest that most migraine drugs are unlikely to cause any harm during pregnancy. This includes drugs such as ImigranTM. So, if you find out that you are pregnant and have taken drugs to treat a migraine, don’t worry, but do have a chat with your doctor just to make sure. However, it is still recommended to avoid using drugs during pregnancy unless absolutely necessary.
If you need to treat migraine, paracetamol is safe throughout pregnancy and breastfeeding. Aspirin is also safe, but should not be taken close to giving birth since it can cause problems with bleeding. The anti-sickness drug prochlorperazine has been used for pregnancy-related nausea for many years. Drugs that promote the absorption of painkillers and also treat nausea such as metoclopramide and domperidone have also been used widely during pregnancy but are probably best avoided during the first three months. For frequent attacks warranting daily preventative treatment, propranolol has best evidence of safety
Hysterectomy
There is no evidence to suggest that a hysterectomy is of any benefit in the routine treatment of hormonal headaches. The normal menstrual cycle is the result of the interaction of several different organs in the body. These include organs in the brain, in addition to the ovaries and the womb.
Removing the womb alone has little effect on the hormonal fluctuations of the menstrual cycle even though the periods cease, although it may help heavy, painful periods. Removal of the ovaries puts the body into an instant menopause, often making migraine worse for a few years. The effect of oestrogen replacement therapy to replace ovarian function has not been studied. However, such treatment may help to control symptoms in women with migraine who need a hysterectomy for gynaecological reasons.
