How to manage a patient with migraine with aura and abnormal uterine bleeding?

Managing Migraine with Aura and Abnormal Uterine Bleeding

Avoid combined hormonal contraceptives (CHCs) in this patient, as migraine with aura is an absolute contraindication due to increased stroke risk, and use progestin-only methods or non-hormonal approaches for both conditions. 1, 2

Critical Contraindication

• Combined hormonal contraceptives are absolutely contraindicated in women with migraine with aura due to unacceptable stroke risk, as classified by the U.S. Medical Eligibility Criteria for Contraceptive Use 2016. 2
• This contraindication takes precedence even though continuous CHCs (without placebo pills) would otherwise be an effective treatment for menstrually-related migraines by preventing estrogen withdrawal. 2

Acute Migraine Management

• Start with NSAIDs (ibuprofen 400-800 mg every 6 hours or diclofenac potassium) for mild to moderate attacks, as these are first-line treatment with well-documented efficacy. 1
• Use triptans for moderate to severe attacks that don't respond to NSAIDs, but avoid triptan use during the aura phase itself. 1
• Acetaminophen has limited efficacy and should only be used if the patient is intolerant to NSAIDs. 1

Preventive Migraine Treatment

• Initiate beta-blockers (propranolol, metoprolol, atenolol, or bisoprolol) as first-line preventive therapy if migraines significantly interfere with daily activities despite acute treatment. 1
• Consider topiramate 50-100 mg daily as an alternative first-line preventive option. 1
• Reserve third-line options (onabotulinumtoxinA, CGRP monoclonal antibodies like erenumab or fremanezumab) for refractory cases. 1
• Absolutely avoid valproate sodium in women of childbearing age due to teratogenicity. 1, 3

Abnormal Uterine Bleeding Workup

• Obtain pregnancy test and CBC with platelets immediately to rule out pregnancy and assess for anemia or thrombocytopenia. 4
• Perform transvaginal ultrasound (TVUS) combined with transabdominal approach as the initial imaging modality to evaluate for structural causes (polyps, adenomyosis, leiomyomas, malignancy). 5
• Consider endometrial sampling based on risk factors for endometrial cancer, particularly if the endometrium cannot be completely visualized on ultrasound. 5
• If TVUS is inadequate due to body habitus or uterine pathology, proceed to MRI pelvis with diffusion-weighted imaging for superior tissue characterization. 5

AUB Treatment Options (Safe with Migraine with Aura)

• Levonorgestrel intrauterine device (LNG-IUD) is an excellent option as it provides local progestin effect without systemic estrogen exposure, treating both AUB and providing contraception. 4
• Tranexamic acid (antifibrinolytic) can be used for heavy menstrual bleeding without hormonal effects. 4
• Progestin-only pills or depot medroxyprogesterone acetate are safe alternatives for hormonal management without estrogen. 4
• NSAIDs serve dual purpose: acute migraine treatment and reduction of menstrual blood loss. 1, 2

Menstrually-Related Migraine Considerations

• If migraines are specifically menstrually-related (occurring day 1 ± 2 of menstruation), use short-term prophylaxis with NSAIDs or triptans starting 2 days before expected menses. 1, 2
• This perimenstrual prophylaxis addresses the estrogen withdrawal trigger without using contraindicated CHCs. 2

Treatment Monitoring

• Evaluate treatment response within 2-3 months using headache frequency, severity, and disability measures. 1
• Have the patient maintain a headache calendar documenting symptomatic days to track patterns and treatment efficacy. 1
• Monitor for medication-overuse headaches by limiting acute medication use and avoiding opioids or butalbital-containing analgesics. 1

Common Pitfalls to Avoid

• Never prescribe combined hormonal contraceptives, even if the patient requests them for AUB management—the stroke risk with migraine with aura is unacceptable. 2
• Don't use valproate for migraine prevention in women of reproductive age due to teratogenicity. 1, 3
• Avoid using triptans during the aura phase itself, only after headache begins. 1
• Don't overlook coagulopathies as a cause of AUB, especially if the patient has had bleeding problems since menarche. 5