From the Guidelines
For a patient with migraine with aura, progesterone (hormone replacement therapy) pills are not recommended to delay her menstrual period due to the potential increased risk of stroke associated with estrogen-containing products, and instead, progestin-only options like norethindrone can be considered at a dose of 5-10 mg daily. When considering hormone therapy to delay menstruation in patients with migraine with aura, it's crucial to prioritize the safety and minimize the risk of stroke, as estrogen-containing products are contraindicated in these patients 1. The use of progestin-only pills such as norethindrone is preferred because they do not increase the risk of stroke and can effectively delay menstruation by stabilizing the endometrial lining and preventing menstrual shedding. Some key points to consider when prescribing norethindrone for this purpose include:
- Starting the medication 2-3 days before the expected period and continuing until the patient is ready for menstruation to occur
- Tapering the medication over 2-3 days rather than stopping it abruptly to minimize breakthrough bleeding
- Advising the patient about potential side effects such as breakthrough bleeding, breast tenderness, and mood changes
- Recommending a backup plan such as menstrual products for travel, as this method may not completely prevent menstrual bleeding for everyone. It's also important to note that the provided evidence does not directly support the use of progesterone for delaying menstruation in patients with migraine with aura, but rather emphasizes the importance of avoiding estrogen-containing products in these patients 1.
From the Research
Migraine with Aura and Hormone Replacement Therapy
- The use of combined hormonal contraceptives (CHCs) for menstrual migraine with aura is not recommended due to the increased risk of unacceptable health risks, especially when other risk factors such as smoking are present 2.
- For women with menstrual migraine, including those with aura, other treatments such as GnRH agonists, selective estrogen receptor modulators, and bilateral oophorectomy have limited evidence 2.
Progesterone as a Treatment Option
- There is no direct evidence to support the use of progesterone (hormone replacement therapy) pills to delay menstrual periods for 1 week in patients with migraine with aura.
- However, depot progestogen can be an alternative for women who are contraindicated to combined oral contraceptives, as it inhibits ovulation and can improve migraine, provided amenorrhoea is achieved 3.
- The use of progesterone derivatives or non-oral routes of delivery is recommended to minimize the exacerbation of migraine, with continuous regimens used where possible 3.
Dose and Duration of Progesterone
- There is no specific recommendation for the dose and duration of progesterone for delaying menstrual periods in patients with migraine with aura.
- The evidence suggests that stable estrogen levels have a positive effect on minimizing or eliminating the estrogenic drop, which can trigger migraine attacks 4.
- The use of progesterone-only contraception has little place in the management of menstrual migraine, as it does not inhibit ovulation and is often associated with a disrupted menstrual cycle 3.