Review Evaluates Effects of Exogenous Estrogens and Progestogens on Migraine During Reproductive Age

As migraine is significantly more prevalent in women than men—likely due to fluctuations in estrogen levels—researchers conducted a systematic review of data involving the effect of exogenous estrogens and progestogens on the course of migraine during reproductive age, resulting in recommendations for clinical decision making.

However, the researchers established the need for further research on this topic to expand the knowledge about the use of estrogens and progestogens in women with migraine.

The review involved the European Headache Federation representatives, who selected a panel of international multidisciplinary experts in migraine and hormonal contraception (HC), including headache experts, gynecologists, and epidemiologists. The representatives were chosen to provide evidence-based guidance to clinicians for the management of migraine with exogenous estrogens and progestogens, according to the authors. Key papers on potential benefits of the use of estrogens and progestogens in migraine were used and assessed in the review.

“Several attempts were made to manipulate the female hormonal cycle to try to improve migraine,” the authors stated. “As in users of combined hormonal contraceptives (CHCs) migraine attacks mostly occur during the hormone free interval, studies also evaluated how different estrogen or progestogen regimens impact on the course of migraine. CHCs have been associated with an increased risk of ischemic stroke in women with migraine.”

The researchers defined pure menstrual migraine (PMM) as attacks that are exclusively related to menstruation and defined menstrually related migraine (MRM) as attacks that occur at other times of the cycle. In 11 studies treatment was used for headache prevention, in 8 studies treatment effect on headache was evaluated in women who required treatment for contraception or medical reasons, and in 2 studies prescribed treatment was not specified.

The review revealed that all of the recommendations assessed were based on low-quality evidence and that there is limited evidence overall in reference to the use of estrogens and progestogens in women.

“The strength of recommendation was rated as low in all cases. Further, most of the contraceptive hormone strategies were evaluated in the gynecological setting in women who required estrogens and/or progestogens for contraception or medical reasons,” the authors explained. “Much more limited is the evidence on the use of those drugs in the headache setting in women who do not require them for gynecological reasons.”

Despite the limited evidence, the authors suggested that desogestrel 75 μg /day pill offered more evident benefit on migraine course and may be the safest form from a cardiovascular point of view. They also suggested that the administration of estradiol gel may be the best therapeutic option for women who have menstrual attacks of migraine during natural cycles.

Overall, the available evidence is weak and further studies are needed to establish whether the treatments discussed may be applied to treat migraine in women, according to the review.

Reference:

Sacco S, Merk-Feld G, Egidius K, et al. Effect of exogenus estrogens and progestogens on the course of migraine during reproductive age: a consensus statement by the European Headache Federation (EHF) and the European Society of Contraception and Reproductive Health (ESCRH) [published online August 31, 2018]. J Head Pain. https://doi.org/10.1186/s10194-018-0896-5.