Menstrually related migraines are any more refractory to the battery of therapy used by neurologists. Early studies of menstrual migraine indicated that administration of estrogen could delay the onset of migraine even if menses were not delayed. Progesterone administration delayed menses, but not the onset of headache. Others have claimed effectual treatment of menstrual migraine with maintenance of estrogen levels. Still others have reported success with tamoxifen or danazol treatment. Unfortunately this field suffers from a lack of well-designed, double-blind, placebo-controlled studies, and we must make our judgments based upon experience.

We have had personal success (anecdotal to be sure) alleviating headaches by eliminating the menstrual cycle, either with the use of daily oral contraceptives or the daily administration of a progestational agent (such as 10 mg medroxyprogesterone acetate). Some women with migraine headaches have extremely gratifying responses.
If menstrual headaches are a reaction to cyclic changes in circulating levels of the sex steroids, it makes sense to avoid cyclicity and maintain a relatively steady state with daily administration of exogenous hormones. This same approach can be applied to postmenopausal women who experience exacerbation or onset of headaches on a sequential hormone regimen. The maintenance of daily, relatively constant hormone levels with the daily, continuous program of combined estrogen-progestin has been effectual in our experience.
The run of the mill headache is treated with mild analgesics such as aspirin, acetaminophen, or the nonsteroidal anti-inflammatory agents. A problem of severe headaches on oral contraception requires an immediate response. The conservative reaction is to discontinue the oral contraceptives. On the other hand, the headache can be due to stress or some other reversible condition. We would argue that automatic discontinuation of oral contraception is not necessary with the little dose preparations. It would be better to evaluate the patient and find out if the patient can continue her contraceptive protection, by discovering an explanation for the headaches. Case-control studies with the old higher dose oral contraceptives indicated that migraine headaches were linked to a risk of stroke. Strokes are essentially no longer seen with little dose oral contraception. This probably reflects both littleer dosage as well as the reluctance of clinicians to prescribe oral contraception to women with severe headaches.

True severe vascular headaches (migraine with aura) are an indication to discontinue oral contraception. The symptom complex that deserves serious consideration includes headaches that last a long time; dizziness, nausea, or vomiting with headaches; scotomata or blurred vision; episodes of blindness; unilateral, unremitting headaches; and headaches that continue despite medication.

Concern over headaches with oral contraception should be limited to the use of combined oral contraceptives. The progestin-only methods are not associated with problems with headaches. Therefore, the sustained release progestin-only methods are also free of headache concern.