How to manage migraines worsened by birth control pills?

Question

Hello doctor,

I have had migraine headaches since I was 16, but they became much worse after I started taking birth control pills two years ago. I now experience attacks 15 to 20 times per month, and each episode lasts two to three days. The pain is severe, throbbing, and mostly on the left side of my head.

I take Sumatriptan 100 mg, but it only works about half of the time and often makes me feel dizzy and nauseous. My neurologist prescribed topiramate for prevention, but I gained 25 pounds and developed significant brain fog, which affected my work as an accountant.

My migraines always worsen just before my period and during ovulation, which makes planning daily activities very difficult. I also experience visual auras with flashing lights, which are frightening, especially while driving. Bright lights and loud sounds trigger attacks immediately, so I often need to wear sunglasses even indoors.

My gynecologist suggested switching to a progesterone-only pill, but I am concerned about irregular bleeding. I tried Botox injections, but my insurance does not cover them. The chronic pain has started to affect my relationship, and I feel depressed most days.

I would like to know which migraine treatments are safe to use with hormonal contraceptives and whether changing birth control methods could help reduce the frequency of my migraines.

Thank you.

Answer 1

Hello,

Welcome to icliniq.com

I read your query and can understand your concern.

Your history of migraine with aura (a type of migraine that includes visual symptoms such as flashing lights or zigzag patterns), along with a marked worsening after starting an estrogen-containing birth control pill (combined oral contraceptives that contain both estrogen and progesterone), and clear menstrual and ovulatory triggers, strongly suggests that estrogen is increasing both the frequency and severity of your migraines.

In general, combined oral contraceptives that contain estrogen are not recommended for women with migraine with aura because they increase the risk of stroke (a sudden interruption of blood flow to the brain), especially when migraine attacks are frequent.

Because of this, switching to a progesterone-only method, such as the mini-pill, a hormonal intrauterine device (IUD), or an implant, is usually safer for women with migraine with aura. In some women, these methods may also reduce hormonally triggered migraine attacks. Although irregular bleeding can occur, it is a common side effect and usually improves within the first few months. In addition, non-hormonal options, such as the copper intrauterine device, are available and completely avoid hormonal migraine triggers.

For migraine prevention, you and your neurologist may consider non-estrogen preventive treatments that are generally well tolerated. These include CGRP monoclonal antibodies, such as Erenumab, Fremanezumab, and Galcanezumab. Other options include beta-blockers, such as Propranolol or Metoprolol, or antidepressants like Venlafaxine. Each option should be chosen based on your overall health and medical history. Since Botox injections (OnabotulinumtoxinA, a treatment that relaxes pain-triggering nerve signals) are not covered by your insurance, CGRP injections may be a more accessible alternative if insurance approval is possible.

Along with medications, strict trigger management is very important. Maintaining regular sleep, staying well hydrated, eating meals on time, limiting exposure to bright lights, and using tinted migraine glasses can all help reduce attack frequency. Finally, close coordination between your neurologist and gynecologist can provide the best approach to safely managing both migraines and hormonal changes.

Kindly revert if there are any queries.

Thank you.

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