What treatment options are available for patients with migraine with aura influenced by estrogen?

Treatment Options for Migraine with Aura Influenced by Estrogen

For patients with migraine with aura influenced by estrogen, combined hormonal contraceptives are contraindicated due to increased stroke risk, and treatment should focus on non-estrogen preventive therapies including beta-blockers, anticonvulsants, and perimenstrual preventive strategies. 1

Understanding Migraine with Aura and Estrogen Relationship

• Migraine with aura affects approximately 15-33% of migraineurs and involves fully reversible focal neurological phenomena (visual, sensory, speech, and/or motor symptoms) that typically precede the headache phase 2
• Estrogen fluctuations significantly influence migraine, with estrogen "withdrawal" triggering menstrual attacks of migraine without aura, while high estrogen levels are associated with migraine aura 3
• Women with migraine with aura have a significantly increased risk of ischemic stroke compared to those without aura 1, 2

First-Line Preventive Treatment Options

Beta-Blockers

• Propranolol (80-160 mg oral once or twice daily in long-acting formulations) 1
• Metoprolol (50-100 mg oral twice daily or 200 mg modified-release oral once daily) 1
• Atenolol (25-100 mg oral twice daily) 1
• Bisoprolol (5-10 mg oral once daily) 1

Anticonvulsants

• Topiramate (50-100 mg oral daily) - contraindicated in nephrolithiasis, pregnancy, lactation, glaucoma 1

Angiotensin II-Receptor Blockers

• Candesartan (16-32 mg oral per day) 1

Second-Line Preventive Treatment Options

• Amitriptyline (10-100 mg oral at night) - contraindicated in heart failure, glaucoma, and with monoamine oxidase inhibitors 1
• Flunarizine (5-10 mg oral once daily) - caution with parkinsonism, depression 1
• Sodium valproate (600-1,500 mg oral once daily) - absolutely contraindicated in women of childbearing potential 1

Third-Line Preventive Treatment Options

• OnabotulinumtoxinA (155-195 units to 31-39 sites every 12 weeks) 1
• CGRP monoclonal antibodies:
  • Erenumab (70 or 140 mg subcutaneous once monthly) 1
  • Fremanezumab (225 mg subcutaneous once monthly or 675 mg subcutaneous once quarterly) 1
  • Eptinezumab (100 or 300 mg intravenous quarterly) 1

Acute Treatment Strategies

• First-line: NSAIDs (ibuprofen, naproxen, diclofenac) 1
• Second-line: Triptans when headache begins (not during aura phase) 1, 2
• For menstrual migraine attacks: Start NSAIDs or aspirin as soon as possible during aura phase to prevent or diminish headache 2

Special Considerations for Estrogen-Influenced Migraine

Contraceptive Management

• Combined hormonal contraceptives are contraindicated in women with migraine with aura due to increased stroke risk 1
• This contraindication applies regardless of any association with the menstrual cycle 1
• For women with pure menstrual migraine without aura, continuous use of combined hormonal contraceptives may be beneficial 1

Perimenstrual Prevention

• For menstrual-related migraine, consider perimenstrual preventive treatment 1:
  • Long-acting NSAID (e.g., naproxen) for 5 days, beginning 2 days before expected menstruation 1
  • Long-acting triptan (e.g., frovatriptan or naratriptan) using same schedule 1

Monitoring and Follow-up

• Evaluate treatment response within 2-3 months after initiation or change in treatment 1
• Use headache calendars to track attack frequency, severity, and medication use 1
• Key outcome measures: attack frequency (headache/migraine days per month), attack severity, and migraine-related disability 1

Common Pitfalls to Avoid

• Failing to distinguish between migraine with aura and without aura when prescribing contraceptives 1
• Using combined hormonal contraceptives in women with migraine with aura, which increases stroke risk 1, 4
• Administering triptans during the aura phase rather than waiting for headache onset 1, 2
• Not considering perimenstrual prevention strategies for women with menstrual-related migraine 1
• Prescribing sodium valproate to women of childbearing potential 1

By following these evidence-based guidelines, clinicians can effectively manage migraine with aura influenced by estrogen while minimizing stroke risk and optimizing patient outcomes.