What is the recommended treatment for a female patient of childbearing age with migraine with aura, considering the use of Provera (medroxyprogesterone acetate)?

Treatment of Migraine with Aura in Women of Childbearing Age: Provera as a Safe Alternative

For women of childbearing age with migraine with aura, progestogen-only contraception such as Provera (medroxyprogesterone acetate) is the recommended hormonal option, as combined hormonal contraceptives are absolutely contraindicated due to increased stroke risk. 1

Why Combined Hormonal Contraceptives Are Contraindicated

• Combined hormonal contraceptives are absolutely contraindicated in women with migraine with aura regardless of any association with their menstrual cycle, owing to an associated increase in the risk of stroke. 1

• Migraine with aura itself carries an odds ratio of approximately 6 for ischemic stroke, and when combined with oral contraceptives (which carry an odds ratio of approximately 2), the cumulative risk becomes unacceptable. 2

• This contraindication applies even to modern low-dose formulations, as current guidelines from the Nature Reviews Neurology consensus statement maintain this restriction. 1

Provera and Progestogen-Only Options as Safe Alternatives

• Progestogen-only contraception, including medroxyprogesterone acetate (Provera), is recommended as a safer alternative because it does not appear to be associated with an increased risk of venous thromboembolism or ischemic stroke. 3

• The maintenance of stable estrogen levels through progestin administration in ovulation-inhibiting dosages may positively influence the nociceptive threshold in women with migraine. 3

• Preliminary evidence suggests that progestogen-only pills (such as desogestrel 75μg) have a positive effect on both migraine with aura and migraine without aura, reducing the number of migraine days, analgesic use, and intensity of associated symptoms. 3

Acute Migraine Treatment Recommendations

For acute migraine attacks in women of childbearing age with migraine with aura:

• First-line acute treatment should be paracetamol 1000 mg, which can be repeated as needed while avoiding medication overuse (limit to <15 days per month). 4

• Ibuprofen and other NSAIDs (naproxen, diclofenac) are safe and effective alternatives. 4

• Triptans (such as sumatriptan) are NOT contraindicated for acute treatment in migraine with aura. The stroke risk associated with migraine with aura relates to estrogen in combined hormonal contraceptives, not to acute triptan therapy. 4

• Limit triptan use to <10 days per month to prevent medication overuse headache. 4

Preventive Treatment Options

For women of childbearing age with migraine with aura requiring preventive therapy:

• First-line preventive medications include:

  • Propranolol 80-160 mg oral once or twice daily in long-acting formulations 1
  • Candesartan 16-32 mg oral per day 1
  • Topiramate 50-100 mg oral daily (though contraindicated in pregnancy) 1

• Second-line options include:

  • Amitriptyline 10-100 mg oral at night 1
  • Flunarizine 5-10 mg oral once daily 1

• Sodium valproate is absolutely contraindicated in women of childbearing potential. 1

Critical Clinical Pitfalls to Avoid

• Never prescribe combined hormonal contraceptives to women with migraine with aura, even if they request them for menstrual migraine management. 1

• Do not withhold triptans for acute treatment solely because the patient has migraine with aura—the contraindication applies only to combined hormonal contraceptives, not acute triptan therapy. 4

• Avoid ergotamine derivatives and dihydroergotamine entirely. 4

• Do not use opioids or butalbital-containing medications due to risks of dependency and rebound headaches. 4

• If the patient develops new aura symptoms or worsening of aura while on any hormonal contraception, discontinue immediately and reassess. 2

Additional Risk Factor Assessment

When prescribing any contraception or migraine treatment to women with migraine with aura, evaluate for additional stroke risk factors:

• Smoking status 1, 2
• Hypertension 1, 2
• Diabetes 1, 2
• Hyperlipidemia 1, 2
• Thrombophilia 5, 2
• Age over 35 years 1, 2

The presence of multiple risk factors further supports the use of progestogen-only contraception like Provera over any combined hormonal option.