Transcript American College of Ostetricians and Gynecologists (ACOG

LA CEFALEA NELLA DONNA
SEGRATE, 11 marzo 2006
CEFALEA E PILLOLA: COSA NE PENSA
IL GINECOLOGO ITALIANO?
Massimo Luerti
U.O. OSTETRICIA E GINECOLOGIA 1
[email protected]
Those “controlled” trials that exist do not
suggest a strong, durable relationship
between OC use and headache for most
women. In controlled trials, increases in
headache activity occur in the early cycles of
OC use, but few or no persistent
statistical differences can be
demonstrated in headache activity among
groups of women who receive OCs and those
in control groups.
(Livello di prova ASCO I)
Headache as a side effect of combination estrogenprogestin oral contraceptives: A systematic
Susceptibility to OC-associated
headache also appears to increase
with age
The risk of developing headache
with OC use is higher in patients
over 35 years of age (Livello di prova ASCO IV)
Headache and treatment with oral contraceptives. Larsson-Cohn U, Lundberg PO. Acta Neuro Scand. 1970;46:267-268
The 150/30 formulatio. Experience in the United Kingdom. J Reprod Med 1983;28 (suppl 1):66-70
Some women do appear to have a higher
risk of headache exacerbation or new-onset
headache attributable to OC use. This higher
risk is most apparent in women with a strong
personal or family history of troublesome
headaches, particularly migraine. The
incidence also increases with age. Even
within these higher risk groups, some women
note improvement in headache with OC use;
most women report no change in overall
headache activity, and headache complaints
decrease with continued use. (Livello di prova
ASCO I)
Headache as a side effect of combination estrogenprogestin oral contraceptives: A systematic review
Recommendations regarding OC use in selected
primary headache disorders
(Spaulding Rehabilitation Hospital, Headache and pain Program, Boston, MA, Forza B)
TENSION-TYPE HEADACHE
• Not a contraindication to OC use
CLUSTER HEADACHE
• Insufficient evidence for any recommendations regarding OC use in
this rare headache syndrome that is more common in men
WOMEN WITH NO PERSONAL BUT A STRONG
FAMILY HISTORY OF HEADACHE OR
MIGRAINE
• Modest evidence of increased risk of headache precipitation with
OC use, especially if over the age of 35; monitor closely if OCs are
used
Recommendations regarding OC use in selected
primary headache disorders
(Spaulding Rehabilitation Hospital, Headache and Pain Program, Boston, MA Forza B)
MIGRAINE WITHOUT AURA
•Not a contraindication to OC use in patients under 35 or without additional stroke
risk factors
•Clinical judgment should be used in deciding whether advantages of OC use may
outweigh risks in selected patients over 35 or with other stroke risk factors
•Monitor frequency and severity of headaches during use of Ocs
•Reassess use if headaches worsen or neurologic accompaniments develop (e.g.,
aura)
MIGRAINE WITH AURA
•Consider alternative forms of birth control
•Recognize that there is a spectrum of aura severity, ranging from prolonged,
dramatic auras with every headache to aura experienced only once or twice during a
lifetime. Common sense and expert opinion suggests that the stroke risk may vary
accordingly; definitive evidence on this point is lacking and clinical judgment
should be used.
American College of Ostetricians and Gynecologists (ACOG) and World
Health Organization (WHO) Guidelines for the use of Combination
Estrogen-Progestin Oral Contraceptives in Women with Migraine
(2000-2001 Forza B)
Variable
Age  35 years
ACOG
Guidelines
WHO
Guidelines
Risk usually
Risk usually
outweighs benefits outweighs benefits
Focal symptoms Risk unacceptable Risk unacceptable
MIGRAINE WITH AURA
Some genes linked to VT seem to influence the
susceptibility to the disease.
The C677T variant in the MTHR is significantly over
represented compared to controls.
An increased frequency of activated protein C resistance,
due to Arg506Gln factor V mutation, and of protein S
deficiency has been demonstrated in patients suffering
from migraine, overall if with aura. (Livello di prova ASCO II)
A thorough laboratory control of the genetics of
prothrombotic factors and coagulative parameters should
precede any decision of OCs prescription in migraine
patients.
OC use and migraine are
independent risk factors for
ischemic stroke
Risk
migraine without aura
3
migraine with aura
6 to 8
migraine, smoke, and OCs 34
(Livello di prova ASCO III)
Becker WJ. Use of oral contraceptives in patients with migraine.
Neurology 1999;41:786-93
International Headache Society Task Force
Recommendations on Combined Oral Contraceptive
Use in Women with Migraine (2000 Forza B)
1.
2.
3.
4.
5.
Identify and evaluate risk factors
Diagnose migraine type, particularly the presence of aura
Women with migraine who smoke should stop smoking before
starting COCs
Other risk factors, such as hypertension and hyperlipidemia,
should be treated
Consider nonethinylestradiol methods in women who are at
increased risk of ischemic stroke, particularly those who have
multiple risk factors. Some of these contraceptives are as or more
effective in preventing pregnancy than COCs and include
progestogen-only hormonal contraception. Observational
studies suggest that progestogen-only hormonal contraceptive use
is non associated with an increased risk of ischemic stroke,
although quantifiable data are limited.
International Headache Society Task Force
Recommendations on Combined Oral Contraceptive
Use in Women with Migraine (2000 Forza B)
Migraine-related symptoms that may necessitate
further evaluation and or cessation of COCs
1. New persisting headache
2. New onset of migraine aura
3. Increased headache frequency or intensity
4. Development of unusual aura symptoms,
particularly prolonged aura
International Headache Society Task Force
Recommendations on Combined Oral Contraceptive
Use in Women with Migraine (2000 Forza B)
“An increase in attack frequency or severity with
Ocs is itself an indication for stopping OC,
whether or not it is associated with an increased
risk of stroke. A change in the character of
attacks after starting OC use is possibly of greater
concern, but the evidence is conflicting”
Switching to OCs that contain a very low dose of estrogen,
does not improve headache.
This paradox may be due to the fact that OCs with very low
estrogen doses do not suppress ovarian function
completely.
Headache activity in the last few days of active pills could
be explained by the fact that combination low-dose OCs with <
35 mg of ethinyl estradiol do not reliably produce complete
ovarian suppression and that estrogen levels decline during
the last week of active pills before the hormone-free interval
(Livello di prova ASCO IV)
Headache as a side effect of combination estrogenprogestin oral contraceptives: A systematic review
Elizabeth W. Loder, MD,a Dawn C. Buse, PhD,b Joan R. Golub, MDc
American Journal of Obstetrics and Gynecology (2005) 193, 636–49
Fitzgerald C, Feichtinger W, Spona J, Elstein M, Ludicke F,
Muller U, et al. A comparison of the effects of two monophasic
low dose oral contraceptives on the inhibition of ovulation. Adv Contraception 1994;10:5-18.
Killick SR, Fitzgerald C, Davis A. Ovarian activity in women
taking an oral contraceptive containing 20 mg ethinyl estradiol and
140 mg desogestrel: effects of low estrogen doses during the
In case of OCs assumption, the first choice should
be a combined monophasic regimen…………….
………………………the continuos intake of Ocs
for 42 or 63 days can reduce the number of
menstrual attacks
(Livello di prova ASCO IV)
Oral contraceptives in women with migraine: balancing risks and benefits
G. Allais, C. De Lorenzo, O. Mana, C. Benedetto.Neurol. Sci (2004) 25:S211-S214
EP vaginali
Eighty-three subjects (58%) reported headache
when they used OCs, compared with only 11 women
(8%) with vaginal use, a difference that was highly
statistically significant. (Livello di prova ASCO IV)
Vaginal steroids are ‘‘absorbed gradually into the
systemic circulation and can reach the target organs
in the hypothalamic-pituitary–ovarian axis without
first undergoing passage through the liver.’’
,
ZiaeiS,RajaeiL,FaghihzadehS LamyianM.Comparative study and
evaluation of side effects of low-dose contraceptive pills administered
by the oral and vaginal route. Contraception 2002;65:329-31
The dose and type of
progesterone in OCs
does not appear to
influence headache
(Livello di prova ASCO IV)
Koetsawang S, Charoenvisal C, Banharnsupawat L, Singhakovin
S, Kaewsuk O, Punnahitanont S. Multicenter trial of two monophasic
oral contraceptives containing 30 mg ethinylestradiol and
either desogestrel or gestodene in Thai women. Contraception 1995;51:225-9.
Dunson TR, McLaurin VL, Isrankura B, Leelapattana B,
Mukherjee R, Perez-Palacios G, et al. A comparative study of
two low-dose combination oral contraceptives. Contraception 1993;48:109-19.
NONHORMONAL TREATMENT STRATEGIES
Multivitamin supplement that was given to 500
women in conjunction with OCs had no effect on a
number of adverse events, including headache.
(Livello di prova ASCO IV)
The use of diuretics for those women with headache
on
OCs did not produce relief.
Headache as a side effect of combination estrogenprogestin oral contraceptives: A systematic review
Elizabeth W. Loder, MD,a Dawn C. Buse, PhD,b Joan R. Golub, MDc
American Journal of Obstetrics and Gynecology (2005) 193, 636–49
EMICRANIA E GRAVIDANZA
Significativo miglioramento della
frequenza delle crisi di emicrania
nel corso dei 3 trimestri di
gravidanza con una completa
remissione a termine pari al 78,8%
(Livello di prova ASCO IV)
R. Nappi, S. Detaddei Cefalea e ormoni. http://www.cefalea.it/ormoni1.cfm 2002
SONDAGGIO PRESSO
UN CAMPIONE DI
GINECOLOGI ITALIANI
QUANDO UNA VOSTRA PAZIENTE RIFERISCE
DI SOFFRIRE DI “MAL DI TESTA”, PROCEDETE
AD UNA DIAGNOSI DIFFERENZIALE TRA I
DIVERSI TIPI DI CEFALEA?
35%
Sì
No
57%
8%
A volte
IN PRESENZA DI UNA PAZIENTE
CEFALALGICA IN TRATTAMENTO
ESTROPROGESTINICO, RICHIEDETE LA
COMPILAZIONE DI UNA CARTA-DIARIO
30%
46%
Sempre
Mai
A volte
24%
IN PRESENZA DI UNA FAMILIARITÀ
CEFALALGICA IN UNA PAZIENTE
ASINTOMATICA RITENETE LA
PILLOLA CONTROINDICATA
3%
Sempre
Mai
53%
44%
Dipende dal tipo di
cefalea
IN PRESENZA DI UNA PAZIENTE
CEFALALGICA SENZA FATTORI DI
RISCHIO E SENZA AURA RITENETE
LA PILLOLA CONTROINDICATA
5%
8%
Sempre
Mai
87%
Dipende dal tipo di
cefalea
IN PRESENZA DI UNA EMICRANIA
CON AURA RITENETE LA
PILLOLA CONTROINDICATA
2%
65%
Sempre
28%
5%
Mai
Dipende dalla presenza
di fattori di rischio
Non risponde
PRIMA DI PRESCRIVERE UN
TRATTAMENTO ESTROPROGESTINICO,
RICHIEDETE UNO SCREENING PER LA
TROMBOFILIA CONGENITA
Sempre
11%
28%
7%
54%
Mai
Solo in presenza di
fattori di rischio
Solo in presenza di
emicrania con aura
SE IN CORSO DI TRATTAMENTO
EP COMPARE CEFALEA :
Sospendete il
trattamento EP
4%
29%
Riducete il dosaggio
38%
Attendete qualche
mese
29%
Passate a una pillola a
base di solo
progestinico
SE IN CORSO DI TRATTAMENTO
EP PEGGIORA LA CEFALEA
Sospendete il
trattamento EP
Riducete il dosaggio
7%
4% 1%
Attendete qualche
mese
21%
67%
Passate a una pillola a
base di solo
progestinico
Non risponde
PER OVVIARE ALLA CEFALEA DA
SOSPENSIONE IN CORSO DI
PILLOLA
Non suggerite nulla
1%
22%
34%
43%
Suggerite l'uso di
estrogeni durante la
settimana di intervallo
Suggerite un uso
continuo, senza
interruzione, per alcuni
mesi
Non risponde
SE UNA PAZIENTE CEFALALGICA VI
INTERROGA SULLE CONSEGUENZE DI UNA
GRAVIDANZA SULLA SUA CEFALEA, LE
RIFERITE CHE LA GRAVIDANZA:
2%
8%
29%
61%
Aumenta il rischio di
cefalea
Diminuisce il rischio di
cefalea
Non modifica il rischio
di cefalea
Non risponde