How should I manage persistent weekly headaches in a 31‑year‑old woman with hypertension treated with perindopril 2 mg daily, low‑dose amitriptyline 10 mg daily, and the combined oral contraceptive Seasonique (ethinyl estradiol/norgestimate)?

Discontinue Seasonique Immediately and Optimize Headache Management

This patient must stop Seasonique (combined oral contraceptive) immediately due to the absolute contraindication of combined hormonal contraceptives in women with hypertension, which increases her risk of myocardial infarction 6-68 fold and ischemic stroke 3-15 fold. 1, 2

Critical Contraceptive Issue

Combined hormonal contraceptives are absolutely contraindicated in women with hypertension, regardless of control status. 1, 2

• Seasonique contains ethinyl estradiol (estrogen component), which stimulates hepatic synthesis of angiotensinogen, further activating the renin-angiotensin-aldosterone system and raising blood pressure 2
• Even with controlled hypertension on perindopril, this patient faces 6.1-68.1 times higher odds of myocardial infarction compared to normotensive non-users 2
• Risk of ischemic stroke increases 8-15 fold in hypertensive women using combined oral contraceptives 1, 2

Recommended Contraceptive Alternatives

Switch to a copper IUD (Category 1 for all hypertensive women) or progestin-only methods (Category 2). 3, 4

• Copper IUD: <1% failure rate, no hormonal effects on blood pressure, no cardiovascular risk amplification 3
• Levonorgestrel IUD: <1% failure rate, minimal systemic hormone absorption 3
• Etonogestrel implant (Nexplanon): <1% failure rate, first-line hormonal option for hypertensive women 3, 4
• Progestin-only pills: 6-12% typical-use failure rate, no significant blood pressure elevation in studies 3

Headache Management Optimization

The current amitriptyline dose of 10 mg is subtherapeutic for migraine prevention; increase to 25-100 mg nightly. 1

Assess Headache Pattern First

• Determine if headaches are migrainous (pulsating, unilateral, moderate-severe intensity, aggravated by activity, with nausea/photophobia) or tension-type 1
• If migraine with aura is present, this creates an additional absolute contraindication to combined hormonal contraceptives beyond hypertension alone 1
• Headaches lasting up to 7 days suggest either chronic migraine (≥15 headache days/month) or medication overuse if acute medications are used frequently 1

Optimize Preventive Treatment

Amitriptyline is second-line preventive therapy; titrate from current 10 mg to 25-50 mg nightly, with maximum dose of 100 mg if needed. 1

First-line preventive options that also benefit hypertension include: 1

• Beta-blockers: Propranolol 80-160 mg daily (long-acting), metoprolol 50-100 mg twice daily, or bisoprolol 5-10 mg daily
• Angiotensin II receptor blocker: Candesartan 16-32 mg daily
• Anticonvulsant: Topiramate 50-100 mg daily (contraindicated if planning pregnancy)

Consider Switching from Perindopril to Candesartan

Candesartan 16-32 mg daily provides both first-line migraine prevention and hypertension control, potentially addressing both conditions with one medication. 1

• Current perindopril 2 mg daily is a low dose; typical effective doses are 4-8 mg daily 5, 6, 7
• If blood pressure is not optimally controlled on perindopril 2 mg, switching to candesartan offers dual benefit 1

Blood Pressure Reassessment

Verify current blood pressure control on at least two separate occasions before finalizing the treatment plan. 3

• Perindopril 2 mg is below the typical therapeutic dose of 4-8 mg daily for hypertension control 5, 6, 7
• Target blood pressure should be <130/80 mmHg 3
• If blood pressure is elevated, uptitration of perindopril or addition of a diuretic (indapamide) may be needed 8, 9
• Discontinuing Seasonique should result in blood pressure reduction within 2-6 months 1, 3

Monitoring Requirements

Check blood pressure monthly until controlled, then every 6 months for any woman using hormonal contraceptives (including progestin-only methods). 2, 3, 4

Implement headache diary tracking for 2-3 months to assess:

• Headache frequency (days per month) 1
• Severity and disability 1
• Acute medication use (to identify potential medication overuse) 1
• Response to preventive treatment changes 1

Common Pitfalls to Avoid

• Do not continue combined oral contraceptives even if blood pressure appears controlled – the cardiovascular risk amplification persists regardless 1, 2
• Do not assume 10 mg amitriptyline is adequate for migraine prevention – therapeutic doses start at 25 mg and range to 100 mg 1
• Do not overlook the potential for medication overuse headache if acute medications are used >10-15 days per month 1
• Do not delay contraceptive counseling – pregnancy risk exists immediately upon stopping Seasonique without alternative contraception 3