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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 massimo.luerti@ao.lodi.it.

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slide1

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

massimo.luerti@ao.lodi.it

slide2
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 reviewElizabeth W. Loder, MD,a Dawn C. Buse, PhD,b Joan R. Golub, MDcAmerican Journal of Obstetrics and Gynecology (2005) 193, 636–49

slide3
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;46:267-268The 150/30 formulatio. Experience in the United Kingdom. J Reprod Med 1983;28 (suppl 1):66-70

slide4
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 reviewElizabeth W. Loder, MD,a Dawn C. Buse, PhD,b Joan R. Golub, MDcAmerican Journal of Obstetrics and Gynecology (2005) 193, 636–49

slide5

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
slide6

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.
slide7

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)

slide8

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.

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

slide9
OC use and migraine are independent risk factors for ischemic stroke

Risk

migraine without aura3

migraine with aura6 to 8

migraine, smoke, and OCs34

(Livello di prova ASCO III)

Becker WJ. Use of oral contraceptives in patients with migraine.Neurology 1999;41:786-93

slide10
International Headache Society Task Force Recommendations on Combined Oral Contraceptive Use in Women with Migraine (2000 Forza B)
  • 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.
slide11
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

  • New persisting headache
  • New onset of migraine aura
  • Increased headache frequency or intensity
  • Development of unusual aura symptoms, particularly prolonged aura
slide12
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”

slide13
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 reviewElizabeth W. Loder, MD,a Dawn C. Buse, PhD,b Joan R. Golub, MDcAmerican 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 monophasiclow dose oral contraceptives on the inhibition of ovulation. Adv Contraception 1994;10:5-18.

Killick SR, Fitzgerald C, Davis A. Ovarian activity in womentaking an oral contraceptive containing 20 mg ethinyl estradiol and140 mg desogestrel: effects of low estrogen doses during thehormone-free interval. Am J Obstet Gynecol 1998;179(suppl): S18-24.

slide14
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

slide15
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 andevaluation of side effects of low-dose contraceptive pills administeredby the oral and vaginal route. Contraception 2002;65:329-31

slide16
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, SinghakovinS, Kaewsuk O, Punnahitanont S. Multicenter trial of two monophasicoral contraceptives containing 30 mg ethinylestradiol andeither 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 oftwo low-dose combination oral contraceptives. Contraception 1993;48:109-19.

slide17
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 reviewElizabeth W. Loder, MD,a Dawn C. Buse, PhD,b Joan R. Golub, MDcAmerican Journal of Obstetrics and Gynecology (2005) 193, 636–49

emicrania e gravidanza
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

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QUANDO UNA VOSTRA PAZIENTE RIFERISCE DI SOFFRIRE DI “MAL DI TESTA”, PROCEDETE AD UNA DIAGNOSI DIFFERENZIALE TRA I DIVERSI TIPI DI CEFALEA?
slide21
IN PRESENZA DI UNA PAZIENTE CEFALALGICA IN TRATTAMENTO ESTROPROGESTINICO, RICHIEDETE LA COMPILAZIONE DI UNA CARTA-DIARIO
slide22
IN PRESENZA DI UNA FAMILIARITÀ CEFALALGICA IN UNA PAZIENTE ASINTOMATICA RITENETE LA PILLOLA CONTROINDICATA
slide23
IN PRESENZA DI UNA PAZIENTE CEFALALGICA SENZA FATTORI DI RISCHIO E SENZA AURA RITENETE LA PILLOLA CONTROINDICATA
slide25
PRIMA DI PRESCRIVERE UN TRATTAMENTO ESTROPROGESTINICO, RICHIEDETE UNO SCREENING PER LA TROMBOFILIA CONGENITA
slide29
SE UNA PAZIENTE CEFALALGICA VI INTERROGA SULLE CONSEGUENZE DI UNA GRAVIDANZA SULLA SUA CEFALEA, LE RIFERITE CHE LA GRAVIDANZA: