118) A 30-year-old woman has been using oral contraceptive pillls, combination type for past 8 yrs. However, she also has a history of migraines. Lately, she has been experiencing an average of 14 episodes of severe migraine without aura yearly. Careful evaluation of her headache calender reveals that most of them occur exclusively during the pill-free week of her OC regimen. She has no history of smoking. She has never had DVT or family hx of thrombophilia. Her physical exam is normal without any neurological deficits. Next step in management ?
A. Switch to low dose estrogen pills
B. Switch to minipill
C. Discontinue OC pills
D. Start extended duration OC pills like seasonale
B
B
D
Dr Red please tell the answer.
Thanks
D
D
can someone clarify? if someone is <35 and no history of aura, then they can continue low dose of the same medication
A)Switch to low dose estrogen pill
Approach-21 days OCP(Combined)+Start low dose estrogen
approach 2-Take OCP(Combined) for 28 days for 3-6 months
b
switch to minipill,
its progesteron which is causing the problem so either we need to discontinue pills or start low dose estrogen in drug free period but if we do so how patient is going to have breakthrough bleeding
so the best is stop ocp and advise for iucd
so c is best answer
need answer from dr red
Combined OCPs are relative CI in Migrane. Isn’t it estrogen which is causing the problem?
A
no aura 30 y/o dicr the head ache w/ strogenic pills them use it extended d? or a? please dr red?
The migraine here occurs during the pill free weeks. In such cases, the migraine classically occurs two days after withdrawing OCPs and has no aura and the patient will have 12-14 episodes/year. Here, the culprit is Estrogen lack which is insufficient to suppress ovarian fn and so they suffer withdrawal effect and will have migraine -classically called as Pill free migraine. The treatment should be aimed at providing estrogen in the pill free week, not progesterone(mini pill)( progesterone is the cause in fact)- (so not choice B) . And low dose estrogen won’t be enough to suppress the ovarian function( not choice A). There is no need to discontinue OCPs- discontinue only if migraine is severe with aura since it could cause thrombosis and stroke. ( not choice C)You can’t keep taking the OCPs in the breakthrough period( though there could be breakthrough bleed even with continuous OCPs, there are adverse effects of continuous OCPs like metabolic and thrombotic side effects. So, the best treatment is to provide an extended dosage OCP like sesonale. so choice D would be the best option.
The migraine here occurs during the pill free weeks. In such cases, the migraine classically occurs two days after withdrawing OCPs and has no aura and the patient will have 12-14 episodes/year. Here, the culprit is Estrogen lack which is insufficient to suppress ovarian fn and so they suffer withdrawal effect and will have migraine -classically called as Pill free migraine. The treatment should be aimed at providing estrogen in the pill free week, not progesterone(mini pill)( progesterone is the cause in fact)- (so not choice B) . And low dose estrogen won’t be enough to suppress the ovarian function( not choice A). There is no need to discontinue OCPs- discontinue only if migraine is severe with aura since it could cause thrombosis and stroke. ( not choice C)You can’t keep taking the OCPs in the breakthrough period( though there could be breakthrough bleed even with continuous OCPs, there are adverse effects of continuous OCPs like metabolic and thrombotic side effects. So, the best treatment is to provide an extended dosage OCP like sesonale. so choice D would be the best option.
DrMahesh Narayanan, good explanation!
Usmle Galaxy thanks !!!
That answer makes a whole lot of sense.
Thanks for the explanation.