Overview
Definition:
Migraine with aura is a neurological disorder characterized by recurrent headache preceded or accompanied by transient neurological symptoms (aura), typically visual but can be sensory, motor, or speech disturbances
Contraception choices in adolescents with this condition require careful consideration due to potential increased risks of thromboembolic events, particularly with combined hormonal contraceptives.
Epidemiology:
Migraine is common in adolescence, affecting approximately 15-20% of girls
Aura occurs in about 20-30% of migraine sufferers
The incidence of VTE in the general population using combined hormonal contraceptives is around 2-6 per 10,000 woman-years, but this risk is significantly elevated in women with specific risk factors, including migraine with aura.
Clinical Significance:
Appropriate contraceptive selection is vital to prevent unintended pregnancies and manage reproductive health in adolescent females
However, the presence of migraine with aura introduces specific contraindications for certain contraceptive methods, necessitating a thorough risk-benefit assessment to ensure patient safety and prevent serious adverse events like stroke or VTE.
Clinical Presentation
Symptoms:
Recurrent headaches, typically unilateral, pulsating, moderate to severe intensity, aggravated by physical activity
Aura symptoms preceding or accompanying headache: visual disturbances (scintillating scotoma, flashing lights), sensory symptoms (paresthesias, numbness), speech difficulties, motor weakness (hemiplegic migraine).
Signs:
Neurological examination may be normal between attacks
During aura, transient focal neurological deficits may be observed
No specific vital sign abnormalities are consistently present
Funduscopic examination can reveal papilledema in rare cases of increased intracranial pressure.
Diagnostic Criteria:
International Headache Society (IHS) criteria for Migraine with Aura (e.g., ICHD-3 criteria)
Key elements include at least two attacks fulfilling specific aura criteria and at least two headache criteria, with exclusion of other causes.
Diagnostic Approach
History Taking:
Detailed headache history: frequency, duration, intensity, location, associated symptoms, triggers, aura characteristics (type, duration, progression)
Family history of migraines or VTE
Personal medical history including any cardiovascular risk factors, smoking status, current medications
Menstrual cycle correlation
Red flags: new-onset headache, sudden severe headache, focal neurological deficits persisting beyond aura, headache with fever or stiff neck.
Physical Examination:
Complete neurological examination to assess cranial nerves, motor strength, sensation, coordination, gait, and reflexes
Funduscopic examination
Cardiovascular assessment
Examination for signs of venous stasis or thrombosis.
Investigations:
Generally, investigations are not required for typical migraine with aura in the absence of red flags
Neuroimaging (MRI brain) may be considered to rule out secondary causes if atypical features are present or if neurological deficits persist
Doppler ultrasound of lower limbs to assess for VTE if clinically suspected
Thrombophilia screening if recurrent VTE is suspected.
Differential Diagnosis:
Transient Ischemic Attack (TIA), epilepsy, reversible cerebral vasoconstriction syndrome (RCVS), cerebellar strokes, vertebrobasilar insufficiency, retinal migraine, basilar artery migraine, hemiplegic migraine.
Management Considerations
Contraceptive Risk Assessment:
The primary concern is the increased risk of ischemic stroke and venous thromboembolism (VTE) associated with combined hormonal contraceptives (CHCs) in women with migraine with aura
The World Health Organization (WHO) Medical Eligibility Criteria for Contraceptive Use (MEC) provides a framework for assessing risks.
Contraindications For Chcs:
MEC Category 4: CHCs (combined oral, transdermal patch, vaginal ring) are generally contraindicated for women with migraine with aura, especially if they are over 35 years old, smoke, or have other cardiovascular risk factors
The presence of aura itself significantly increases the risk of stroke
Even in younger, non-smoking individuals, the risk is considered unacceptable by many guidelines.
Alternative Contraceptive Options:
Progestin-only methods are generally considered safer
These include: Progestin-only pills (POPs), etonogestrel implant, depot medroxyprogesterone acetate (DMPA) injection, and the levonorgestrel-releasing intrauterine system (LNG-IUS)
These methods do not contain estrogen and therefore do not carry the same thromboembolic risks
However, a thorough discussion of benefits, risks, and side effects is still warranted for each individual patient.
Non Contraceptive Options:
For adolescents seeking contraception for menstrual regulation or management of other gynecological issues, non-contraceptive estrogen-containing medications should also be approached with extreme caution
Referral to a specialist (neurologist or adolescent medicine physician) is often recommended for complex cases.
Key Points
Exam Focus:
Recall the WHO MEC categories for contraceptive use in women with migraine with aura
Understand the specific risks associated with combined hormonal contraceptives (CHCs) compared to progestin-only methods
Differentiate between migraine with and without aura in the context of contraceptive choice.
Clinical Pearls:
Always inquire about headache type and associated neurological symptoms when counseling on contraception
Emphasize shared decision-making with adolescent patients
Progestin-only methods are generally the preferred contraceptive choice for individuals with migraine with aura
Document the rationale for contraceptive choice clearly in the patient's medical record.
Common Mistakes:
Prescribing combined hormonal contraceptives without adequately assessing for migraine with aura or its risk factors
Underestimating the risk of stroke and VTE in this population
Not offering or discussing safer progestin-only alternatives
Failing to involve specialists when indicated.