0093-7002/82/5910-0821$02.00/0 AMERICAN JOURNAL OF OPTOMETRY & PHYSIOLOGICAL OPTICS Copyright © 1982 American Academy of Optometry case report Vol. 59, No. 10, pp. 821-823 Printed in U.S.A. Migraine and Oral Contraceptives GEORGE Y. MOUSA* School of Optometry, University of Waterloo, Waterloo, Ontario, Canada ABSTRACT Migraine is a common complaint in optometric practice. Three cases of migrainous patients taking oral contraceptives are presented in this report. The role of oral contraceptives in triggering a migraine attack and possibly ele- vating the risk of a stroke in a patient with migraine is discussed. The counseling an op- tometrist can provide in such cases is dis- cussed. Key Words: migraine, oral contraceptives, triggering factors, stroke Migraine is characterized by periodic, usually unilateral headache often associated with pho- tophobia, nausea, vomiting, and occasionally ac- companied by scotomas, hemianopia, or unilat- eral paresthesia." * In 20% of these patients the headache is preceded by auras and visual dis- turbances secondary to the vasoconstriction of the cranial arteries. The subsequent vasodilata- tion of the same arteries causes a severe throb- bing headache.” The duration of migraine head- ache varies from several hours to several days and its frequency varies from one to three times a week to once every 2 years.”* Sometimes migraine can be relieved by the administration of vasoconstrictive agents, e.g., ergotamine.° Migraine headaches may be precipitated by any one of many factors: stress and worry, men- struation, oral contraceptives, glare and dazzle, physical exertion, lack of sleep, hunger, head trauma, or use of food and beverages containing nitrate, glutamate, or tyramine (cheese, yogurt, nuts, beans, chocolates, pork, and liver).”° Mi- graine patients are at higher risk of having a stroke. This risk may be related to an increased Received November 30, 1981; revision received March 31, 1982. * Optometrist, Ph.D., Member of Faculty. tendency for their platelets to aggregate.’ Plate- lets with similar characteristics were found in patients suffering from sustained cerebral infarc- tion.’ Hence the risk of stroke is higher if the patient takes oral contraceptives.’ This may be explained by the fact that oral contraceptives also cause changes in the intima of blood ves- sels.'° These changes along with the hyperag- gregability of platelets in migraine sufferers may precipitate a stroke. CASE REPORTS First case: a 27-year-old white female accoun- tant complained of temporal throbbing head- aches associated with nausea, vomiting, hazy vision, small scotomas, and photophobia. She had been getting the headaches twice a month since 1978 and she took Fiorinal to relieve them. Her headaches were diagnosed as migraine by her family physician. The patient acknowledged that she started getting these headaches after beginning to use oral contraceptives 3 years ear- lier. The patient’s medical history was normal except for temporary borderline high blood pres- sure 2 years earlier, which became normal (122/ 90) after she lost weight (20 pounds). Her family history revealed that her mother had severe migraine headaches which sometimes were ac- companied by unilateral paresthesia, as well as high blood pressure. The patient’s grandmother had diabetes and cataracts. The patient’s spec- tacle prescription was: OD, —2.00 T —1.25 x 005 20/15; OS, —2.00 = —1.75 x 164 6/4.5 (20/ 15). Ophthalmoscopy, slitlamp, accommodation, and intraocular pressure findings were unre- markable. The patient was counseled about the factors which can trigger a migraine attack and was advised that eliminating these factors”® may reduce the frequency and intensity of the head- aches. Furthermore, the patient was advised that oral contraceptives could increase her risk of having a stroke, especially with her family 821 822 AM J OPTOM & PHYSIOL OPTICS history. The patient was encouraged to discuss this matter with her family physician, who had prescribed the oral contraceptives (similar coun- seling was provided to the other two patients reported below). When the patient was con- tacted 5 months later, she reported that her physician had reduced the dosage of her oral contraceptive. She added that she was trying to avoid the migraine-triggering factors (for exam- ple, she was wearing her sunglasses). Her head- aches had become less frequent and less severe. Second case: a 21-year-old white female stu- dent complained of throbbing headaches on one side or behind the eye. The patient reported that these headaches occurred once every 2 weeks and were not related to reading. She also men- tioned that the headaches were associated with nausea, blurry vision, and seeing sparkling lights. Her headache episodes lasted from 2 to 24 hr. She had been getting these headaches for the last 2 years and they were most severe immedi- ately after she resumed taking oral contracep- tives following each menstrual period. She had been taking oral contraceptives for the last 3 years. She also complained that her eyes got tired after reading for 1 hr. Her health history was normal and her blood pressure was 120/80. Her mother had a history of migraine and her grandmother had high blood pressure. The pa- tient’s unaided vision was 6/4.5 (20/15) each eye, and subjective refraction was: OD, +1.00 20/15; OS, +1.25 6/4.5 (20/15). Ophthalmoscopy, slitlamp, accommodation, and intraocular pressure findings were unre- markable. Reading spectacles OD +1.00, OS +1.25 were given to the patient. Three months later she indicated that she was trying to avoid the migraine-triggering factors. She discussed the matter with her family physician, who told her that she was already on the low estrogen content pill, She reported a decrease in the frequency of her headaches (once each month just after taking the pill) and they were less severe than before. She mentioned that she con- sulted a neurologist, who ruled out any serious causes for the headaches and confirmed that they were migraines. With her reading specta- cles, she could now read comfortably for up to 2 hr. Third case: a 25-year-old white female clerk complained of temporal throbbing headaches associated with photophobia, blurred vision, and nausea. She had been getting these headaches since the age of 12. The headaches had become very severe 7 years earlier, after she started taking oral contraceptives. At that time, she consulted a neurologist, who did a complete neurological work-up and diagnosed the head- aches as migraines and prescribed pills with lower estrogen content. She had been taking Vol. 59, No. 10 those pills and had been getting migraine head- aches once a month right after resuming pill use following her menstrual period. Her headaches lasted from 3 hr to 3 days. The patient took Fiorinal to relieve the headaches. The patient’s health history was normal and her blood pres- sure was 106/64; however, her mother had high blood pressure. The patient was wearing: OD, —0.75 TS —0.25 x 010 20/20; OS, —0.75 = —0.25 X 170 6/6 (20/20). Ophthalmoscopy, slitlamp, accommodation, and intraocular pressure findings were unre- markable. Three months later the patient reported that she was trying to avoid all the migraine-trigger- ing factors—i.e., she had not eaten pork, beans, or chocolates. She had not had a severe head- ache for the last 3 months, and she was still taking the same oral contraceptives. DISCUSSION Migraine is a common headache. Twenty to 25% of the population may experience migraine in their lifetime.'* However, Troost!” indicated that migraine affects only 10% of the population. Most of these patients report their first head- ache between the age of 10 and 40 years, and 75% of the migraine-suffering population are women.° A large proportion of this group may consult their optometrist because the pain af- fects their eyes and they may experience visual disturbances. Many of these patients report headache as their chief complaint and seek help from their eyecare provider. Some of these pa- tients may not know that their headache is migraine. In many individuals the headache may be precipitated or aggravated by oral contracep- tives. For the three patients discussed, oral contra- ceptives seemed to trigger or exacerbate mi- graine headaches. The first two patients started having migraine attacks after commencing the use of oral contraceptives. For the third patient the headaches became so severe after taking the pill that she consulted a neurologist. The second and third patients complained that the head- aches were most severe at the time each month when they resumed use of the pill. None of the three patients discontinued taking oral contra- ceptives. The second and third patients were already using a contraceptive with a low estro- gen dosage, and the first was put on low estrogen dosage after my recommendation to her physi- cian. Thus, encouraging the patients to discuss the dosage of oral contraceptives with their fam- ily physician may be one of the ways to reduce the unwanted effect of the pill. It has been my experience that patients do not readily give up the convenience of the pill for contraception but October 1982 they are willing to use the lower estrogen dosage pills. Discontinuation of oral contraceptives re- duces the frequency and intensity of the mi- graine headache in 70% of patients." The effect of oral contraceptives goes beyond triggering a headache. They may trigger a stroke especially if the patient has a family history of high blood pressure, as did the patients in this study. Differential diagnosis of migraine headaches includes muscle contraction, tension, sinus, and allergic headaches.” The diagnosis of migraine headache is aided by the specific signs and symp- toms associated with migraine, i.e., nausea, pho- tophobia, and visual disturbances. Other serious diseases which may present migraine-like symp- toms include: intracranial arteriovenous malfor- mations, aneurysms, tumors, arterial hyperten- sion, temporal arteritis, and vascular insuffi- ciency. Most of these serious conditions cause sudden onset of continuous and severe head- ache.” “* Optometrists can be most helpful to the pa- tient by counseling them to avoid the triggering factors. Glare is one of the triggering factors which could be reduced by tinted spectacles. This also helps the optometrist to differentially diagnose migraine and enables the patient to identify some of the factors that exacerbate mi- graine. The patient should be advised that con- trolling these factors may decrease the fre- quency and intensity of the headache. ACKNOWLEDGMENTS Thanks are due to Drs. M. J. Samek and Y. J. Allouch- erie for reading the manuscript. REFERENCES 1. Wolff, HG. Headache and Other Head Pain. New York: Oxford University Press, 1961:227-301. 2. Diamond S, Medina JL. Review article: current Migraine and Oral Contraceptives—Mousa 10. 11. 12. 13. 14. 823 thoughts on migraine. Headache 1980;20:208- 12. . Saper JR. Migraine. |. Classification and patho- genesis. JAMA 1978;239:2380-3. . Cohen MJ, McArthur DL. Classification of mi- graine and tension headache from survey of 10,000 headache diaries. Headache 1981;21:25-9. . Ostield AM. A study of migraine pharmacother- apy. Am J Med Sci 1961;241:192-8. . Raskin NH, Appenzeller O. Major Problems in Internal Medicine, vol 19. Headache. In: Smith LH Jr, ed. Major Problems in Internal Medicine: Headache. Philadelphia: Saunders, 1980:28-83. . Couch JR, Hassanein RS. Platelet aggregability in migraine. Neurology 1977;27:843-8. . Kalendovsky Z, Austin J, Steele P. Increased platelet aggregability in young patients with stroke. Diagnosis and therapy. Arch Neurol 1975;32:13-20. Carey, HM. Principles of oral contraception. 2. Side effects of oral contraceptives. Med J Aust 1971;2:1242-50. Irey NS, McAllister HA, Henry JM. Oral contra- ceptives and stroke in young women: a clin- icopathologic correlation. Neurology 1978; 28:1216-9. Waters WE. The prevalence of migraine. Head- ache 1978;18:53-4. Troost BT. Migraine. In: Duane TD, ed. Clinical Ophthalmology, vol 2, chap 19. Philadelphia: Harper & Row, 1981;15-6. Kudrow L. The relationship of headache fre- quency to hormone use in migraine. Headache 1975;15:36-40. Higgins JD. 1981;118:130-9. Headaches. Rev Optom AUTHOR’S ADDRESS: George Y. Mousa School of Optometry University of Waterloo Waterloo, Ontario Canada N2L 3G1