Migraine with Aura and Hormone Replacement Therapy

Primary Recommendation

Combined hormonal contraceptives and estrogen-containing HRT are contraindicated in women with migraine with aura due to significantly increased stroke risk 1, 2, 3

If migraine WITH aura is confirmed: Estrogen-containing HRT is contraindicated 1, 2, 3
If migraine WITHOUT aura only: Estrogen-containing HRT may be considered with caution 3

Beta-blockers, such as Propranolol 80-240 mg/day, metoprolol 50-100 mg twice daily, or atenolol 25-100 mg twice daily, are first-line prophylactic agents for migraine 1, 3
Topiramate: 50-100 mg daily is a first-line prophylactic agent for migraine 3
Candesartan: 16-32 mg daily is a first-line prophylactic agent for migraine, particularly useful if hypertensive 3
Amitriptyline: 10-100 mg at night is a second-line prophylactic agent for migraine 1, 3
Flunarizine: 5-10 mg daily is a second-line prophylactic agent for migraine where available 1
CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab, eptinezumab) are third-line prophylactic agents for migraine if first and second-line options fail 3
OnabotulinumtoxinA is a third-line prophylactic agent for chronic migraine 1, 3

Never use combined hormonal contraceptives in migraine with aura - this is an absolute contraindication 1, 2, 3

Women with pure menstrual migraine WITHOUT aura may benefit from continuous combined hormonal contraceptives, but this does not apply to migraine with aura 1, 3
Perimenstrual prophylaxis with NSAIDs (naproxen) or triptans (frovatriptan, naratriptan) for 5 days starting 2 days before menses can be effective for menstrually-related attacks 1, 3