From the Guidelines
There is an absolute contraindication to using combined hormonal contraceptives (estrogen-containing birth control pills) in women who experience migraines with aura. Women with migraines with aura should avoid estrogen-containing contraceptives, including combined oral contraceptive pills, the contraceptive patch, and the vaginal ring, due to the increased risk of stroke associated with estrogen use in this population, as noted in the 2024 guideline for the primary prevention of stroke 1. The aura symptoms are particularly concerning as they indicate a neurological process that may share mechanisms with stroke.
Key Points to Consider
- Estrogen increases the risk of stroke in individuals with migraines with aura, who already have a somewhat elevated stroke risk due to the condition itself 1.
- Progestin-only contraceptive methods are safe alternatives for women with migraines with aura, including progestin-only pills (mini-pills), hormonal IUDs, the implant (Nexplanon), or Depo-Provera injections, as they do not increase stroke risk and provide effective contraception 1.
- Women who develop migraines with aura while already taking combined hormonal contraceptives should discontinue them immediately and consult their healthcare provider about switching to a progestin-only method.
Recommendations
- In individuals with specific stroke risk factors, such as migraine with aura, who are considering contraception, shared decision-making is recommended to determine the best contraceptive choice to balance the risk of stroke from contraception and the risk of stroke with pregnancy 1.
- Progestin-only contraception or nonhormonal contraception is reasonable to prevent the increased stroke risk associated with estrogen-containing contraception in individuals with specific stroke risk factors, including migraine with aura 1.
From the Research
Absolute Contraindication to Oral Birth Control and Migraines with Aura
- The use of combined oral contraceptives is always contraindicated in patients with migraine with aura, as it increases the risk of ischemic stroke 2, 3, 4, 5.
- Migraine with aura is a significant risk factor for ischemic stroke, with an odds ratio of approximately 6 5.
- The combination of migraine with aura and oral contraceptive use results in an unacceptable increase in ischemic stroke risk, especially in older women and those with other stroke risk factors 5.
- Current guidelines restrict the use of combined hormonal contraceptives in patients with migraine with aura due to concerns of increased stroke risk 6.
Risk Assessment and Considerations
- The risk of stroke associated with oral contraceptive use in women with migraine with aura is increased, but the absolute risk is low 3, 6.
- The estrogen content of the oral contraceptive, as well as contributing factors such as smoking, age, and hypertension, can alter the stroke risk 6.
- A risk/benefit assessment should be conducted when considering oral contraceptive use in patients with migraine with aura, taking into account the potential benefits of preventing menstrual-related migraine 6.
- Patients with migraine with aura should be monitored for possible changes in their migraine and cautioned against oral contraceptive use if they experience new aura symptoms or an increase in aura frequency 2, 5.