Abstract
We systematically reviewed data about the effect of exogenous estrogens and progestogens on the course of migraine during reproductive age. Thereafter a consensus procedure among international experts was undertaken to develop statements to support clinical decision making, in terms of possible effects on migraine course of exogenous estrogens and progestogens and on possible treatment of headache associated with the use or with the withdrawal of hormones. Overall, quality of current evidence is low. Recommendations are provided for all the compounds with available evidence including the conventional 21/7 combined hormonal contraception, the desogestrel only oral pill, combined oral contraceptives with shortened pill-free interval, combined oral contraceptives with estradiol supplementation during the pill-free interval, extended regimen of combined hormonal contraceptive with pill or patch, combined hormonal contraceptive vaginal ring, transdermal estradiol supplementation with gel, transdermal estradiol supplementation with patch, subcutaneous estrogen implant with cyclical oral progestogen. As the quality of available data is poor, further research is needed on this topic to improve the knowledge about the use of estrogens and progestogens in women with migraine. There is a need for better management of headaches related to the use of hormones or their withdrawal.
Highlights
The role of female hormones in the pathogenesis of migraine is well-recognized [1, 2]
We found 21 studies which evaluated the effects of estrogens and progestogens on headache in women of reproductive age (Fig. 1) [12–15, 29–45]
Five studies were performed in women with migraine without aura (MO) or migraine with aura (MA) not necessarily related to menstruation [12–14, 41, 43], 10 in menstrually related migraine (MRM) or menstrual migraine (MM) [29–39, 43, 45], 4 in pure menstrual migraine (PMM) [29, 35, 38, 39], and 2 in women with and without headache [15, 40]
Summary
The role of female hormones in the pathogenesis of migraine is well-recognized [1, 2]. Appendix criteria for migraine related to menstruation were introduced in 2004, with the second edition of the ICHD (Table 1) [8]. Two entities were recognised: pure menstrual migraine (PMM) where attacks are exclusively related to menstruation; menstrually related migraine (MRM) where attacks occur at other times of the cycle. Both were forms of MO, along with non-menstrual MO or migraine with aura (MA) in the case of MRM. Since the first ICHD classification [7], it was recognized that headache may be attributable to the use of substances or their withdrawal but formal categories referring to estrogens were introduced in the second edition of the ICHD (Table 2) [8]. Evidence for the duration of treatment with estrogen before withdrawal headache occurs is lacking
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