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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!

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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.

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Maybe Birth Control Pills Would Be OK

Talking to Hart about hormonal birth control, migraine and stroke risk got me wondering what my risk really is. If it is low, multiplying the number by eight isn’t that big of a deal. Kersti explains this well in her comment on the post:

[T]he problem with statistics is that they’re misleading. 8 times more likely… 8 times what? You need to find out what the baseline actually is, and you need to find it out for your own ethnicity, gender, circumstances before you know if this is a problem. If for example the baseline is 10% then 8 times is pretty ghastly, however, if the baseline is 0.01% then you’re still at 8 times 99.92% likely to NOT get one.

I’m kind of embarrassed I didn’t think this through before I wrote the post. I’m always urging readers to think critically. No matter how much I recommend caution, I too fall into the trap of fear. “Stroke? Eight times more likely? No way!” is how I reacted yesterday.

According to the American Heart Association’s stroke risk factors, I’m at very little risk. That’s reassuring. I’ll talk with the doctor on Monday and see what she recommends.

Check out the this BBC article on understanding — and critically evaluating — statistics, which Kersti suggested.

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National Headache Awareness Week: Get a Head S.T.A.R.T. on Your Headaches

In recognition of the 15th annual National Headache Awareness Week, the National Headache Foundation (NHF) is announcing a series of events across the country in order to educate the public about types of headache and their impact on daily living, as well as stressing the importance of seeking an accurate diagnosis and appropriate treatments. This year’s National Headache Awareness Week takes place June 1-7, 2008. Nearly 21 million people were reached last year through this successful annual campaign.

“One of our primary goals during National Headache Awareness Week is to gain recognition of headache pain as a real and legitimate condition,” said Dr. Seymour Diamond, Executive Chairman of the National Headache Foundation. “Over 45 million Americans get chronic, recurring headaches. Of this number, nearly 30 million have migraine headaches.”

Activities taking place across the country this week include headache screenings, educational seminars led by expert physicians, menstrual migraine awareness events and a 5-part podcast series focusing on women’s headache issues, a radio news release and the launch of a non-profit NHF channel on YouTube.

This year, the NHF is encouraging sufferers to “Get a Head S.T.A.R.T. on Your Headaches,” offering five easy-to-remember strategies for effective headache management and treatment:

  • Seek diagnosis — Obtaining the correct diagnosis for your headache is the first step toward effective treatment.
  • Triggers — Identify and track your triggers (e.g., foods, stress, hormonal and weather changes) by keeping a headache diary and share this information with your healthcare provider.
  • Advocate — Be an advocate. Be informed. Be a participant in your headache care.
  • Resources — Utilize the National Headache Foundation as a resource. Visit www.headaches.org for the latest information about headache causes and treatments, or call 1-888-NHF-5552.
  • Treatment — Successful treatment may include medications and lifestyle changes. Work with your healthcare provider to find the right plan for you.

For the first time, this year’s campaign is drawing specific attention to menstrual migraines by designating Wednesday, June 4th as National Menstrual Migraine Awareness Day. In support of Menstrual Migraine Awareness Day efforts, the NHF will also be releasing new survey data from a recent poll of its website respondents suffering from menstrual migraine.

Additionally, the NHF is hosting a five-part podcast series specifically addressing women’s headache issues including Hormones & Headache, Contraception & Headaches, Pregnancy & Headache, Menopause & Headaches and Menstrual Migraine. Podcasts and expert questions and answers are available through links on the National Headache Awareness Week page.

This post is adapted from a National Headache Foundation press release. -Kerrie

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Managing Your Period to Manage Migraine

Lybrel, a continuous birth control pill that stops menstruation recently approved by the FDA, may help prevent menstrually associated migraines for some women. Hormonal birth control is often used as a migraine preventive. Many doctors prescribe that patients replace the sugar pills with active pills to suppress menstruation, thus lessening hormonal fluctuations.

Taken each day, Lybrel provides a continuous supply of hormones without a break for a period, ever. It seems creepy to me, but The Well-Timed Period quotes a report that says that periods aren’t as necessary as they seem. Also, I’m one of the few women who actually likes having a period. (Maybe you didn’t want to know that?)

Learn more about “menstrual management” under “How to Skip a Period” on The Well-Timed Period and pokearound the informative blog.