Hormonal Contraception and Hormone Replacement Therapy in People with Headache

  • E. Anne MacGregor
  • Astrid Gendolla
Reference work entry


The International Headache Society (IHS) classifies estrogen-withdrawal headache and exogenous hormone-induced headache. These events can occur as a result of use of hormonal contraceptives and hormone replacement therapy (HRT). Hormonal contraception, particularly combined hormonal contraceptives, is a popular and effective method, with additional non-contraceptive benefits. Combined hormonal contraceptives (CHCs) typically contain synthetic ethinylestradiol. This is more potent than natural estrogen and, coupled with progestogen, inhibits ovulation, thus providing contraceptive efficacy. For many women, migraine improves or they report change in migraine frequency or severity. Migraine without aura during the hormone-free interval is often the result of estrogen “withdrawal.” This can be treated with extended cycle or continuous combined hormonal contraceptives. Migraine with aura is an independent risk factor for ischemic stroke. Additional risk factors, including use of CHCs, further increase risk although the absolute risk of ischemic stroke in young women is low. Several progestogen-only and nonhormonal methods are more effective contraceptive options and are not associated with increased risk of ischemic stroke. On this basis, most authorities consider migraine with aura to be a contraindication to use of CHCs.

Hormone replacement therapy (HRT), although declining in popularity following uncertainty regarding long-term risk versus benefit, is the most effective treatment for moderate-to-severe vasomotor symptoms associated with menopause. HRT uses natural estrogens to supplement or replace ovarian estrogen at levels compatible with mean levels across the menstrual cycle. Doses are usually insufficient to suppress the natural ovarian cycle but sufficiently stabilize the perimenopausal fluctuations that are associated with vasomotor symptoms. Migraine aura is not a contraindication to use of HRT, as HRT does not appear to increase ischemic stroke risk if used for short-term treatment of vasomotor symptoms during the perimenopause. However, current use of HRT has an adverse effect on migraine frequency. Non-oral routes are recommended for women with migraine as these are less likely to have a negative effect on migraine than oral formulations. Further, continuous combined regimes appear to be better tolerated than cyclical combined HRT.


Ischemic Stroke Hormone Replacement Therapy Migraine With Aura Migraine Without Aura Hormonal Contraceptive 
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© Lifting The Burden 2011

Authors and Affiliations

  1. 1.The City of London Migraine ClinicLondonUK
  2. 2.Regionales Schmerzzentrum EssenEssenGermany

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