ORLANDO– Most adolescent girls who report having headaches – including some of those who report migraines with aura – can safely use combined oral contraceptive pills, according to Dr. Sari Kives.
The available literature suggests that there is some resistance to prescribing such contraception for adolescents with headaches, but most adolescents don’t have the types of headaches that are of concern, Dr. Kives of the University of Toronto said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.
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owever, it is important to get a good characterization of the headaches, keeping in mind that teens may have difficulty relating their symptoms, she said.
“It’s important to understand what the headache actually is. Is it a tension headache, which is by far the most common headache you will see in adolescents?” she said, noting that menstrual migraines and classical migraines are less common in adolescents.
Menstrual migraines account for about 7%-8% of migraines, occur 2-3 days before menses, can last throughout the period, don’t occur any other time of the month, and can be quite debilitating. They usually are secondary to estrogen withdrawal, Dr. Kives said, adding that a decade ago, add-back estrogen was commonly given during the week off of oral contraceptives in those with menstrual headaches.
Dr. Sari Kives
Now it is common practice to use continuous pills or extended-cycle pills, she said, explaining that eliminating the estrogen fluctuation improves the headaches.
Classical migraines also occur commonly in adolescent girls. Some may include focal neurological symptoms that may be triggered by hormonal changes, stress, certain foods and beverages, certain scents or fumes, fatigue, hunger, or trauma.
It is important to ask about such symptoms, Dr. Kives said.
“And that’s probably the most important question you can ask. For me, a focal neurological symptom is, ‘I go blind in my left eye. I lose sensation in my right arm,’ ” she said, providing examples.
Some symptoms are characteristic of “atypical aura,” and some are associated with “typical aura” – an important distinction when determining whether combined OCs are safe for a given patient.
Atypical aura usually has sudden unilateral onset and lasts more than 30-60 minutes. Headache may or may not be present, and visual symptoms may include loss of vision, amaurosis fugax (painless transient monocular visual loss), and visual field anomaly. Sensory and motor symptoms can include lower limb anesthesia or hypoesthesia (decrease in sensation).
Typical aura has more progressive onset, lasts less than an hour, and precedes migraine. Patients may experience bilateral scintillating scotoma, fortification spectra, and blurred vision. These are usually limited to visual symptoms, Dr. Kives said, but sensory and motor symptoms can occur. They tend to occur in relation to the visual symptoms, and may affect the upper limbs, mouth, and tongue – causing tingling or pinching sensations.
Individuals who have migraine with aura account for only about 20% of those with migraine headaches, and the vast majority are going to have visual aura.
“They can have sensory and motor symptoms, but the visual ones are the ones where you have to be very specific,” she said, noting that in her experience, 99% of cases are visual.
“If it’s a short visual aura, less than an hour, and it’s not repetitive, I will consider an oral contraceptive pill in this group of patients, but you have to balance it against what their history sounds like,” she said.
Typically, combined OCs are contraindicated in patients with migraine with aura because of an increased risk of cerebrovascular accident, but in Canada, guidelines provide allowances for this “unique group of individuals with migraines with aura that are limited to visual symptoms and that last less than 1 hour,” she said.
Remember that photophobia, phonophobia, nausea and vomiting, visual blurring, and generalized visual spots/flashing lights do not constitute aura, she said.
This is important, because using too stringent a definition of “migraine with aura” will leave a substantial number of individuals with limited contraceptive options, particularly options that are effective and promote cycle control and compliance, she said.
Although there is a definite risk associated with combined OCs in those with migraine with aura – with an added risk in those who smoke, the risks are low in adolescents, compared with older patients.
“The adult women who walks in with hypertension, or who is a smoker who gets oral contraception – that is a very different patient than the 14-year-old who says, ‘I may get flashing lights before my headache, but not on a regular basis.’ Those are completely different entity patients, in my opinion,” Dr. Kives said.