Hormonal Birth Control for Menstrual Migraine & Insurance Denials

Despite the Affordable Care Act’s required coverage of birth control, some insurers are denying coverage of the birth control patch or NuvaRing, NPR reports. There are a few exceptions to the rule, but nearly all health plans are required to cover all FDA-approved birth control. If you have been denied coverage, NPR recommends appealing the denial and contacting your state insurance board.

How is this relevant to headache/migraine/chronic illness? Hormonal birth control is one method of managing menstrually associated migraine attacks, which tend to be more severe than the migraines a woman has other times of the month. The patch and the ring provide a steadier dose of hormones than a pill does, which makes them more effective for this purpose.

I’ve been using NuvaRing continuously (with one-week breaks every three or four months) since January 2010 and it has been tremendously helpful. Now, the most severe migraines I get happen the few times a year I have to stop the ring for a withdrawal bleed. (You can learn more about skipping periods on The Well-Timed Period.)

This method is generally not recommended for women who have migraine with aura, who are at greater risk of stroke if they use hormonal birth control. However, I recommend talking it over with your headache specialist to decide if it is a good option for you, whether you have migraine with or without aura. Given the frequency and severity of my migraines, my headache specialist said he’d advise me to continue using the NuvaRing even if I did have migraine with aura.

(If you don’t want to/can’t use hormonal birth control for some reason, triptans can be used to prevent menstrual migraine attacks.)

I always love to read your comments, but I’m on vacation and won’t be able to reply until the week of Sept. 8. Please don’t think I’m ignoring you!


Migraine and Depression: Disturbing Research Findings

The link between migraine and depression is pretty well established, but some research findings are still disturbing. Such is the case for a large-scale study published in the journal Depression Treatment and Researcher in November 2013. The study, which included 67,000 Canadians, more than 6,000 of whom have migraine, found that depression and suicidal ideation were much higher among migraineurs than non-migraineurs.

A glance at the findings:

  • 8.4% of men with migraine were depressed at the time of the study, while only 3.4% of those without migraine were.
  • 12.4% of women with migraine were depressed, while 5.7% without migraine were.
  • Both men and women with migraine were more likely to have ever considered suicide seriously than those without migraine.
  • 15.6% of men with migraine had considered suicide serious versus 7.9% of men without migraine.
  • 17.6% of women with migraine had considered suicide serious versus 9.1% of women without migraine.
  • Migraineurs, male and female, younger than 30 had a six times higher risk of depression and four times higher odds of suicidal ideation than those 65 and older.
  • Suicidal ideation among those with migraine was also higher in those who were unmarried, had lower household income and/or greater physical limitations.

Reference: Fuller-Thomson, E., Schrumm, M., & Brennenstuhl, S. (2013). Migraine and despair: factors associated with depression and suicidal ideation among Canadian migraineurs in a population-based study. Depression research and treatment, 2013. (The full text of the article is available for free.)


Migraine Could Be the Source of Colic in Infants

Could colic be an early form of migraine? Quite possibly, according to an increasing body of evidence. The latest research, presented at the American Headache Society conference in June, reviewed published studies that either investigated migraine and colic specifically or had collected data on migraine and collect as part of other research.

This meta-analysis focused primarily on three studies and 891 participants in total. In one, infants whose mothers had migraine were 2.6 times more likely to experience colic than those with non-migraineur mothers. Another found that kids or teenagers who had migraine were 6.6 times more to have had colic than those without a later diagnosis of migraine. The third had similar findings to the second.

Colic is harrowing for parents. To be diagnosed with colic, a baby has to cry for at least three hours a day at least three days a week for three or more weeks. According to Amy Gelfand, MD, the lead researcher, 2.2% of parents of one-month-olds with colic said they had shaken, slapped or smothered their child to get them to stop crying. By the time a child with colic reaches six months old, 5.6% of parents admit to doing so.

Obviously, we can’t know what symptoms an infant experiences. There is some comfort in knowing that children often have migraine attacks without head pain and, for those who do have head pain, it generally lasts a much shorter time than for adults. Basically, many of us “grow into” the head pain that is the hallmark symptom of migraine. Nausea, digestive issues, sense hypersensitivity and autonomic symptoms aren’t minor, but at least there’s a decent chance most infants don’t have the excruciating head pain that adults get with migraine attacks.

Reading this research, I’m deluged by a variety of thoughts and questions. Here’s some of what’s running through my mind:

  • This research is fascinating!
  • If this research holds, it would be a tremendous relief for parents to finally have an explanation (that hopefully leads to a treatment) for colic.
  • Imagining an infant having a migraine attack is heartbreaking.
  • How awful that migraine attacks could begin in the earliest weeks of life.
  • What happens between the time colic resolves and a child starts having identifiable migraine attacks? Do they still experience symptoms?
  • Is there any connection between colic and prevalence of chronic migraine?
  • Colic is widely regarded as awful for infants and their parents. If the general public equates colic with migraine, might they have more empathy for migraineurs?
  • Is it selfish and unfair to hope infants with colic will reduce the stigma of migraine? (Though reducing the stigma would benefit those infants throughout their lifetime with migraine.)

I’m sure I’m not the only one with tons of questions and expect lots more research on the topic in coming years.

Want to read more? Medscape has a good overview of the research and conference presentation: Infant Colic May Be Early Migraine.


Predicting Botox Response for Chronic Migraine

When a patient asks if Botox will help them, the usual response is along the lines of, “Quite possibly, but you’ll have to try it to find out.” A patient’s blood levels of calcitonin gene-related peptide (CGRP) could predict whether a person with chronic migraine will respond to Botox, according to a study published in the journal Headache‘s June edition.

Researchers believe that a patient’s CGRP levels could predict whether Botox will be effective with 95% accuracy. In their study of 81 chronic migraineurs, those who had a CGRP level above a certain threshold were 28 times more likely to respond to Botox than those with CGRP levels below that threshold. (If CGRP sounds familiar, it’s probably because the research findings on migraine prevention drugs that made the news this spring are CGRP antibodies.) This is only one study and it was small. More studies will need to investigate and confirm a connection between Botox response and CGRP before doctors will begin checking CGRP levels before giving a patient Botox.

In the meantime, if you’re looking to figure out if Botox will help you, something called pain directionality is the best current predictor. Pain directionality is whether your pain feels like it is exploding, imploding or ocular. People with imploding or ocular pain are more likely to find relief from Botox than those with exploding pain.

Multiple studies have explored the connection between pain directionality and Botox response; here’s one you can read for free. However, headache specialist Alexander Mauskop warns that pain directionality “is not a very reliable predictor because some people have difficulty categorizing their pain in that way and because even if they do describe it clearly one way or another, this predictor is far from 100% accurate.”


The Stress Caused by Illness

We all know that stress can be a cause or a trigger of illness, but we rarely hear about the inverse — that illness itself is a major stressor. In a national poll by the Harvard School of Public Health, the Robert Wood Johnson foundation and NPR, illness, whether one’s own illness or that of a loved one, stands out as huge source of stress.

When asked what their biggest source of stress was in the previous year, 43% of respondents to this open-ended question said health-related problems.

Respondents who were ill or disabled were most likely to have experienced a lot of stress in the month prior to being polled. The top three groups experiencing high stress in the previous month were all health-related:

  • Poor health condition: 60%
  • Disabled: 46%
  • Has a chronic illness: 36%

(The next most common stressor was income less than $20,000, which applied to 36% of respondents.)

Illness is stressful in so many ways: not being able to participate in your normal life, grief and identity loss, not being able to work and financial concerns, being cut off socially, fearing for your quality of life (or life itself), and many, many other issues. There’s also the physical stress of illness itself. Episodes of a illness, like a migraine or cluster headache attack, physically stress the body, as does the daily grind of a chronic disorder.

And, as this poll shows, our most important self-care mechanisms — the ones that are likely to make our bodies and spirits more resilient — go out the window when we’re stressed. The top four things that change when people are stressed? Sleep, proper nutrition, exercise and spiritual practice (listed in descending order).

Stress definitely can be a trigger for a lot of illnesses, but the fact that illness itself is a stressor is too often overlooked. People with chronic illness are told they’d feel better if they reduced their stress. Those who offer such advice are rarely aware that illness itself is responsible for a large part of our stress.

Fortunately, there are programs that specifically teach people how to cope with illness-based (and other) stress. Mindfulness-based stress reduction (MBSR) was a major help for me. Unfortunately, these programs can be expensive in terms of money, time and energy. You can get a decent approximation of the course for less than $30 by reading Full Catastrophe Living and listening to Jon Kabat-Zinn’s Guided Mindfulness Meditation Series 1 CD set. (A lot of libraries carry the book and CDs, so you may be able to introduce yourself to the concepts for no charge). There’s also a $199 interactive online MBSR course offered by the UMass medical school, which developed the program.