By

NuvaRing for Menstrual Migraine: Blood Clot Risk?

Since starting the NuvaRing to manage menstrually associated migraine attacks four years ago, I’ve recommended it to numerous women who have migraine without aura. The NuvaRing is more effective than birth control pills because it provides a steady dose of hormones, while hormone levels still fluctuate throughout the day with the pill. But recent reports have raised questions about NuvaRing’s safety.

All hormonal birth control raises a woman’s risk of blood clots, but there is speculation that NuvaRing users are at greater risk than those who use oral contraceptives. Merck’s agreement to pay a $100 million settlement for thousands of liability lawsuits, announced on Friday, looks rather suspicious.

There are three studies that come into play when considering this risk. NPR summarizes them as:

“One funded by Merck, published in the journal Obstetrics and Gynecology in October, and another funded by the FDA, with data from Kaiser Permanente and Medicaid databases. The former found a similar risk for the ring and combined oral contraceptive pills. The latter found no difference in risk between new users of low-dose combined hormonal contraceptives and the NuvaRing or the birth control patch. (There was a higher risk found with pills that contain drospirenone, which is found in the pill Yaz.)

“But a study from Denmark, published in the British Medical Journal in May 2012, found a notably higher risk of blood clots from NuvaRing. Women using the NuvaRing were about six times more likely to get venous thrombosis than women who didn’t use any form of hormonal contraceptive. Compared to combined oral contraceptives with levonorgestrel, NuvaRing users were about twice as likely to form blood clots.”

Findings from the Danish study are not included in NuvaRing’s U.S. “label” (that’s FDA-speak for the detailed information that’s included with prescriptions). Again from NPR:

“FDA spokeswoman Andrea Fischer told Shots in an email that the agency ‘questioned the design and study population, and did not have the opportunity to independently review the original data.’

“For one thing, the study compares ‘all users,’ rather than just new users. ‘When using any hormonal contraceptive, the risk of blood clots is higher during the first few months of use,’ according to Fischer, so including both new and longtime users in the same study may make it seem like newer contraceptives are riskier, when actually new users of any method are already at a higher risk.”

The new versus all users distinction eased my mind considerably, though it still seemed kind of scary. The rest of NPR’s detailed explanation of the risks calmed me considerably. It’s too much to post here — it’s the entire second half of the long article — but take a look at Birth Control and Blood Clots: Women Still Weighing the Risk if you’re curious or concerned.

Personally, I’m going to continue using it for now. The risk just isn’t that great and I’ve already been on it for four years — if I were going to have problems with it, they probably would have shown up by now.

Still, since I’m older than 35 (the age at which women are warned to stop using hormonal birth control) and my migraines are no longer as constant or as devastating as they were when I started using the NuvaRing, I’ll probably go off it in a few months to see how I do without it. When I started hormonal birth control to manage menstrually associated migraine attacks, triptans were completely ineffective for me. Now that triptans are a viable option, they may ultimately be a better choice than hormonal birth control.

As with any medication, ask your doctor what your individual risk is given your own medical history and what your other treatment options are. With that information in mind, consider how much risk you’re OK with — a minute risk is acceptable for some women, for others any risk is a deal-breaker.

By

Terrible Migraines: Is it birth control pills? Allergies? A bad spell?

My brain has had a rough month. I’ve had brief reprieves, but most of my time has been occupied by terrible migraines. I feel better this morning and am taking full advantage of it.

I’m in my fourth week of birth control pills. I’ve been spotting for the last 10 days, which I assume has contributed to the migraines. I plan to give the experiment a couple more months, but am not sure if I can make it that long.

I’m increasingly certain that allergies trigger at least some of my migraines. You may remember last spring was also horrible for me. Magnesium certainly was a factor. I wonder if allergies were also involved. Taking a Zyrtec yesterday appears to have reduced my agony tremendously. I had to reschedule yesterday’s appointment for allergy tests (for the third time) for later this month. (Please note that although allergies don’t cause migraines, they can be a trigger.)

My outlook is surprisingly good. Especially considering a bad appointment with my headache specialist Monday. The gist of the appointment: I have headaches and migraines that haven’t responded to treatment. With time, headache research will uncover more clues. Until then, why not try some more things in case they help? And I should think about medication to “make life bearable,” like morphine. (That’s a can o’ worms I can’t open right now.)

Back to the good outlook: If I have to live with migraines and headaches, at least I can do it the best way possible. I have a comfortable home; supportive, patient friends and family; and an understanding husband. My insurance covers a variety of treatments. I can stream NPR and audiobooks from the library. I eat good food that I don’t have to make. My life is as good as it can be right now.

I’m sad to not post more on the blog. I want to write about news and research. I want to share resources. I want to write about myself less. I want the blog to be like it was two years ago. Change is inevitable, so I’m trying to not worry about it much. Maybe I’ll get there again, maybe not.

By

This Time Last Year, March 3-10

Posts from The Daily Headache, March 3-10, 2006

Nerve Stimulator-Imposed Restrictions
According to Medtronic’s Living Well newsletter, these activities might be harmful for people with nerve stimulators: using an electric blanket, skiing, sledding, golfing, amusement park rides. Would I have still gotten the implant if I knew about all these limitiations?

Woman Heartbroken After Ending Love Affair
After years of agony, I finally say goodbye to one of the great loves of my life.

Getting the Attention We Deserve
ABC News aired a piece on new treatments for migraine, the first of a three-part series on migraine. It appears to be a good step toward reducing the stigma of migraine.

Acupuncture & Birth Control Deja Vu
Results of new studies on these migraine topics were released.

Pain Resource: Doctors for Pain
Get a glimpse of this excellent website on treating and coping with chronic pain.

The Ultimate Question
I finally try to answer the question about my occipital nerve stimulator that I’m asked the most: How much does it help? Since I had my stimulator removed in September, this post now seems quaint.

News From Annual Pain Meeting
Studies discussed at the American Academy of Pain Medicine‘s meeting included nerve stimulation and opioid levels in the blood of chronic pain patients.

By

A Headache Specialist’s Comments

Christina Peterson, a neurologist (and migraineur), is a blog reader who leaves terrific, educational comments. I always learn a lot from her. Some of her comments on recent posts are so informative that I want to be sure you all see them.

Warnings Proposed for OTC Painkillers

This is a really important post–it can’t be overstated.

In fact, the NYT article, if anything, understates the matter. The truth is that at this time, over 50% of all liver transplants are necessary because of the medical use of acetaminophen. It’s such a big problem that even the makers of Tylenol have run a commercial asking people not to exceed the recommended amount.

Gastritis and ulcers are no fun, and most people have been made aware of the cardiac and blood clot risks of anti-inflammatories like Vioxx and Celebrex, but a lot of people tend to think that ibuprofen and acetaminophen are benign.

They aren’t.

It’s also important to know that a lot of prescription analgesics, like Vicodin, Percocet, Fioricet, Amidrin (and all their generic names), also contain acetaminophen–so don’t double up.

If you are an intermittent migraine sufferer, and not a chronic headache sufferer, a double-blind randomized controlled trial has established that acetaminophen has no role in the treatment of acute migraine. There are better options available.

Men & Women Experience Pain Differently

This is vastly oversimplified. (Well, OK, it’s a newspaper…) But I trust this blog readership to be more sophisticated than the sixth grade level general readership a newspaper shoots for. So.

Most of the studies that have recently emerged have indeed shown a difference in pain processing between men and women. The major difference is that pain processing in women fluctuates with estrogen levels. (Estrogen–it’s our theme of the week, isn’t it? 🙂

Some of the studies available are simplistic and misleading–lab animals were injected with estrogen, and pain thresholds decreased, which led researchers to conclude that therefore, women were weak, and couldn’t tolerate pain as well as men. (Can anyone say, “Researcher bias”?)

But if you think this through, it is counter-intuitive. It makes no sense. Pregnant women have very high estrogen levels–estrogen levels climb throughout pregnancy, until they are very high by the time labor begins.

And menstrually-associated headaches occur when estrogen levels are at their lowest–the day before menstruation begins is the most common day for a menstrual migraine, and that is the day for a drop in estrogen.

Dr. Nancy E.J. Berman, who has done very important research on the effects of hormones on trigeminal neurons and the effects on orofacial pain, TMD, migraine and fibromyalgia, and who won the Wolff Award this year from the American Headache Society, also wrote the chapter on “Sex Hormones” in the book, The Headaches. She has noted that migraine improves both during pregnancy, when estrogen is high, and after menopause, when estrogen is low. She feels that this suggests that it is rapid changes in estrogen and progesterone that serve as a trigger for migraine attacks.

Some studies suggest that women tolerate pain better than men when estrogen levels are higher, and less well than men when estrogen levels drop–we are still discovering whether it is the rate of drop that is critical (likely), or whether it is also the estrogen:progesterone ratio that has an effect.

Other studies have shown that postmenopausal women process pain similarly to men.

I will say this, though: when I do Botox injections in the office, it’s generally not the women who get faint on me. 😉

Birth Control Pill News

This is all well and good…if you are young, and if you do not have migraine with aura.

Please refer to the following from the ACHE website: Will Using Oral Contraceptives Increase the Risk of Stroke?

It is the standard of care amongst headache experts to advise that women with migraine with aura either not use oral contraceptives at all, or use them very judiciously and with aspirin cardiac prophylaxis, and only if there are no significant cardiovascular risk factors. It is also recommended that women who have migraine without aura discontinue oral contraceptives after age 35. Smokers who have migraine should not use oral contraceptives at all.

I recall reading a recent article that surveyed migraine sufferers, and found that a significant proportion of primary care physicians were not aware of current recommendations regarding migraine and oral contraceptives. (I cannot, however, find the article in my giant stack-of-articles-to-be-filed. So, no citation for you–sorry. I think the author was Dr. Elizabeth Loder, but Google is not bringing it up.)

There is also newer data regarding the increased risk of heart disease in women with migraine, which was published in JAMA recently.

This study looked at women over 45, but estrogens, contained in the vast majority of contraceptives, are also a cardiac risk factor.

So–if you are going to proceed with this, be certain your physician knows you are a migraine sufferer (if you are), and research your family history and personal cardiovascular risk factors.

To learn more about and from Dr. Peterson, visit her websites, Migraine Survival and Headquarters Migraine Management.

By

Migraine Preventive Lamictal & the Pill

Lamictal, an anticonvulsant sometimes used for migraine prevention, can reduce the effectiveness of birth control pills. If you’re using any sort of hormonal birth control (like the patch or a vaginal ring) and are prescribed Lamictal, consider using a back up method of birth control.

12/14/05: The link to the news article on this no longer works. While searching for it, I found old information that says that Lamictal doesn’t impede hormonal birth control. I’m sticking with the article I posted on — as they say, better safe than sorry.

2/9/10: I’ve asked several doctors about this potential interaction. All have said it isn’t an issue.