Headache on Contraception

Headache is a common complaint during hormonal contraception. Most are tension type or mild and do not need a change of method. Migraine with aura is the important exception, because it raises the risk of ischaemic stroke and changes the method choice. New or worsening headache, aura or neurological symptoms in a combined method user needs urgent assessment.

Classification.

• Tension type or mild non-migraine headache.
• Migraine without aura: unilateral, throbbing, moderate to severe, with nausea or light and sound sensitivity, without visual or neurological aura.
• Migraine with aura: transient visual, sensory or speech disturbance, building over 5 to 60 minutes before or with the headache.
• Secondary headache: raised blood pressure, intracranial pathology, venous sinus thrombosis, infection.

Danger signs. Abdominal pain, chest pain or shortness of breath, severe headache, eye problems and severe calf pain.

History. Age, headache history before the method, onset relative to starting or changing the method, aura characteristics, duration, frequency, triggers, medicines, smoking, blood pressure, family history of stroke or thrombosis.

Examination. Blood pressure, neurological examination, fundoscopy where possible.

Differential diagnosis. Tension headache, migraine with or without aura, hypertension related headache, medication overuse headache, cerebral venous thrombosis, stroke, idiopathic intracranial hypertension, pituitary disease, infection, and intracranial mass.

Investigations. Blood pressure measurement in every patient. Neuroimaging for new aura, focal deficit, thunderclap onset, persistent worsening headache or papilloedema. Full blood count, pregnancy test and other tests as the history suggests.

Eligibility categories.

Acute headache. Paracetamol 1 g orally every 6 hours, maximum 4 g daily (3 g in liver disease or weight under 50 kg), and ibuprofen 400 mg orally every 8 hours with food, maximum 1.2 g daily. Avoid ibuprofen in creatinine clearance under 30 mL/min, peptic ulcer and anticoagulant use. Both are compatible with breastfeeding.

Combined method user with new migraine with aura or new focal symptoms. Stop the method now, give a method without oestrogen, and arrange urgent assessment for stroke or venous sinus thrombosis.

Combined method user with migraine without aura. Continue if stable and under 35 years. Stop if the headaches worsen, change in character or aura develops.

Progestin-only pill user. If headaches worsen and migraine with aura develops, stop the pill and help choose an alternative method. If no cause is found, counsel and give simple analgesics.

Injectable user. Assess for other causes including raised blood pressure. Reassure if mild. If severe, stop the injectable and refer for evaluation, then help choose another method.

Implant user. Migraine without aura: continue if the patient wishes. Migraine with aura: remove the implant and help choose a method without hormones.

Hypertension related headache. Treat the blood pressure, review the method, and avoid combined methods when blood pressure is 140/90 or higher.

Follow up. Review within 4 to 6 weeks of any change of method or any new treatment.

Method decisions. For migraine with aura, advise a copper intrauterine device or a barrier method and avoid combined methods and, for implant continuation, progestin-only options. Levonorgestrel intrauterine devices are considered by the clinician. Smoking, age over 35 years and hypertension add stroke risk and further support avoiding combined methods.

Referral and escalation. Refer urgently for new focal deficit, thunderclap headache, headache with fever and neck stiffness, papilloedema, or suspected venous sinus thrombosis or stroke.