Is Menopausal Hormone Therapy (MHT) contraindicated in women with a history of ocular migraines?

Menopausal Hormone Therapy in Women with Ocular Migraines

Menopausal hormone therapy (MHT) is contraindicated in women with a history of ocular migraines (migraine with aura) due to the increased risk of stroke. 1

Understanding the Contraindication

• Combined hormonal contraceptives are contraindicated in women with migraine with aura regardless of any association with their menstrual cycle, due to an associated increase in the risk of stroke 1
• This contraindication extends to menopausal hormone therapy, as the estrogen component carries similar vascular risks 1
• Ocular migraines (migraine with aura) specifically represent a risk factor for stroke, cardiac disease, and vascular mortality 2

Scientific Rationale

• Estrogen can modulate neuronal excitability and interact with vascular endothelium of the brain 3
• High estrogen levels can trigger migraine aura, while estrogen withdrawal typically triggers migraine without aura 4
• Platelet activity is increased in women with migraines and is further stimulated by estrogens, potentially increasing thrombotic risk 3
• The FDA drug label for estrogen products warns about retinal vascular thrombosis and recommends discontinuation if there is sudden partial or complete loss of vision, diplopia, or migraine 5

Clinical Implications

• Women with migraine with aura have an increased baseline risk of stroke that may be further elevated with estrogen-containing therapies 2, 3
• The 2024 American Heart Association/American Stroke Association guideline states that in women ≥60 years of age or at elevated risk for cardiovascular disease or stroke, oral estrogen-containing MHT is associated with an excess risk of stroke 1
• The FDA drug label specifically mentions that estrogen products should be permanently discontinued if examination reveals papilledema or retinal vascular lesions 5

Alternative Management Options

• Non-hormonal options for managing menopausal symptoms in women with ocular migraines include:
  • Selective serotonin reuptake inhibitors (SSRIs) such as escitalopram 4
  • Serotonin-norepinephrine reuptake inhibitors (SNRIs) such as venlafaxine 4
  • First-line migraine preventive medications that may also help with some menopausal symptoms: beta-blockers (atenolol, bisoprolol, metoprolol, propranolol) 1
  • Angiotensin II receptor blockers like candesartan may be considered for both migraine prevention and blood pressure control 1

Important Considerations

• If vasomotor symptoms are severe and non-hormonal treatments are ineffective, the lowest possible dose of transdermal estrogen (not oral) may be considered with extreme caution and only after thorough risk assessment 4
• Continuous progestogens (as provided by the levonorgestrel intrauterine system) are preferred over cyclical progestogens if hormonal treatment is absolutely necessary, as cyclical progestogens can have an adverse effect on migraine 4
• Any decision to use MHT in a woman with ocular migraines must carefully weigh the significant increased risk of stroke against potential benefits for symptom relief 1, 3
• Regular monitoring for neurological symptoms and immediate discontinuation if any visual changes occur is essential if MHT is used despite contraindications 5