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Migraine Headaches and Family Planning: What We Think We Know

Published:September 15, 2020DOI:https://doi.org/10.1016/j.mayocp.2020.08.026
      Migraine headache is a nearly ubiquitous neurological disorder that disproportionately affects women and has already been identified as the leading cause of years lived with disability worldwide in women under the age of 50.
      GBD 2015 Disease and Injury Incidence and Prevalence Collaborators
      Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015.
      Not only is this disability associated with features of the disease of migraine itself, but there is also a vast influence that migraine headaches exert on other aspects of life even between attacks. Many people with migraine live in anticipation of their next attack, which is often unpredictable, and plan their life accordingly.
      • Brandes J.L.
      The migraine cycle: patient burden of migraine during and between migraine attacks.
      As one can imagine, this has many negative consequences, from bearings on a person’s social life, to their career advancement, to their relationships with friends, colleagues, and family.
      • Leonardi M.
      • Raggi A.
      A narrative review on the burden of migraine: when the burden is the impact on people’s life.
      In this issue of Mayo Clinic Proceedings, Ishii et al
      • Ishii R.
      • Schwedt T.J.
      • Kim S.-K.
      • Dumkrieger G.
      • Cheng C.D.
      • Dodick D.W.
      The impact of migraine on pregnancy planning: insights from the American Registry for Migraine Research.
      present their original research demonstrating the impact of migraine on one of the most consequential of issues; family planning. The authors used the American Registry for Migraine Research (ARMR) database for their research and included all adult women with migraine who answered the registry’s questions pertaining to family planning. Their analysis revealed that almost 20% of the women with migraine in the ARMR database chose to avoid pregnancy because of their diagnosis. These women tended to be younger, experienced attacks in temporal relationship with their menstrual cycle, and also carry a diagnosis of chronic migraine. The most commonly cited concerns for choosing to avoid having a child centered around worries that migraine might worsen during or after pregnancy (72.5%), lead to a difficult pregnancy (68.3%), or make parenting difficult (82.6%). Furthermore, 76% of women were concerned that their inability to discontinue migraine medications could harm their baby’s development, and 72.3% were apprehensive about passing on migraine to their child. These numbers are staggering, as are the details of why these women chose to avoid pregnancy.
      It was striking that almost 20% of women with migraine in the ARMR database attested to pregnancy avoidance because of migraine. These are individuals who are being followed in headache specialty clinics, and this result points to the correlation between migraine disease severity and the bearing it has on significant life decisions. Clinicians need to be aware of this association, particularly as we attempt to embody a more patient-centric approach to health care. Discussions regarding a patient’s potential interest in pregnancy need to occur starting at the initial appointment, and for women who might not be interested at that time, the door needs to be left open for future dialogue should they desire. It would be very helpful for patient education guidelines around this topic to be created, as we currently lack this formal guidance, and the inconsistency in which counseling is provided is the unfortunate consequence.
      This paper also sheds light on many of the misconceptions that patients have about migraine and the real-life impact of those beliefs. For example, Ishii et al
      • Ishii R.
      • Schwedt T.J.
      • Kim S.-K.
      • Dumkrieger G.
      • Cheng C.D.
      • Dodick D.W.
      The impact of migraine on pregnancy planning: insights from the American Registry for Migraine Research.
      explained that patient apprehension that migraine would worsen during pregnancy was a frequently cited reason as to why a woman with migraine chose to avoid pregnancy. This finding speaks to a missed opportunity for clinicians to adequately educate patients about their disease, as pregnancy is a time when many actually experience migraine improvement.
      • Kvisvik E.V.
      • Stovner L.J.
      • Helde G.
      • Bovim G.
      • Linde M.
      Headache and migraine during pregnancy and puerperium: the MIGRA-study.
      Many women also expressed the concern as regards passing on migraine to their children; yet, recent research has found that inherited migraine is not predictive of a more severe disease course compared with sporadic migraine.
      • Ravn J.
      • Chalmer M.A.
      • Oehrstroem E.L.
      • Kogelman L.J.A.
      • Hansen T.F.
      Characterization of familial and sporadic migraine.
      These findings are obviously very important to share with patients. The fact that women are choosing to avoid having children based on potentially incorrect risk assumptions underscores the importance of including discussions of pregnancy as part of migraine education. As not all women actively seek out answers from their health care providers on this topic, incorporating it as a standard part of routine counseling with all patients who have migraine seems a prudent approach.
      Migraine medications also played a large role in a woman’s decision to conceive, as 76% of those who chose to avoid pregnancy expressed concern that their medications would cause harm to their child’s development, with 14.1% specifically citing birth anomalies as an adverse outcome. This is another reason why open dialogue with patients is so important, and pregnancy education needs to be part of the conversation from the start, as there are safe ways to manage migraine during pregnancy.
      • Wells R.E.
      • Turner D.P.
      • Lee M.
      • Bishop L.
      • Strauss L.
      Managing migraine during pregnancy and lactation.
      With careful planning many women are able to discontinue preventive medications during this time.
      For women who continue to experience frequent or debilitating attacks during pregnancy and require preventive therapies, we need better longitudinal studies to help provide informed decision making. Our therapeutic arsenal for migraine has expanded significantly in recent years, but the teratogenic effects of the majority of those drugs if taken during pregnancy remains largely unknown. We have pregnancy data regarding the neurodevelopment outcomes of several antiseizure drugs, some of which are also used for migraine prevention,
      • Meador K.J.
      • Baker G.A.
      • Browning N.
      • Cohen M.J.
      • Bromley R.L.
      • Clayton-Smith J.
      • et al.
      Fetal antiepileptic drug exposure and cognitive outcomes at age 6 years (NEAD study): a prospective observational study.
      and similar large longitudinal studies are needed on other commonly prescribed migraine medications in order to best counsel patients.
      The concerns related to migraine medications voiced by the ARMR survey suggest that nonpharmacological options are needed, so that patients have a wider range of therapeutic choices. There is already a recent trend in designing noninvasive neuromodulation devices for this purpose.
      • Halker Singh R.B.
      • Ailani J.
      • Robbins M.S.
      Neuromodulation for the acute and preventive therapy of migraine and cluster headache.
      We also have data indicating that incorporating other therapies such as behavioral treatments, neutraceuticals, and acupuncture into migraine management
      • Patel P.S.
      • Minen M.T.
      Complementary and Integrative Health Treatments for Migraine.
      is helpful. However, for clinicians to recommend nonmedication approaches to migraine on a consistent basis, there is the clear need for additional, larger, randomized trials demonstrating efficacy and safety in pregnancy, and, ideally, comparative trials with medications; such findings can then be incorporated into updated migraine treatment guidelines. Access also needs to be made easier as many of these nonpharmacological options are not covered by insurance, and their use is further limited by cost. These barriers lead patients to rely more on medications, accepting their potential risks, and are placed not infrequently in the predicament of having to make time-sensitive decisions regarding motherhood. The concerns women have about migraine medications as they relate to pregnancy are valid, and we have an obligation to also improve research in other types of treatments to provide alternative options that have reasonable levels of evidence.
      Finally, this paper serves as a call to action for health care providers to be cognizant of our duty to destigmatize migraine and serve as better advocates for our patients. It is heartbreaking to read that the majority of women who are choosing to avoid pregnancy also felt that migraine led to problems in their intimate relationships, and a fifth of patients who stated that they are avoiding pregnancy also endorsed migraine as the reason behind their divorce or separation from their partner. This is a testament to the unrelenting, destructive nature of this chronic invisible diagnosis, which can permeate all aspects of life if left unchecked, including potentially depriving women the opportunity of motherhood should they desire as well as other important relationships. We need to not only support women who have migraine by addressing this patient education gap and improving our treatments to better meet their needs, but also must be deliberate in our efforts to improve societal understanding and acceptance of this prevalent neurobiological disease.

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