From the Guidelines
Combined Oral Contraceptives (COCs) are contraindicated in women with a history of migraine with aura due to the significantly increased risk of stroke, as evidenced by a pooled RR of 2.51 (95% CI, 1.52–4.14) in women with migraine with aura compared to those without aura 1.
Key Points
- Women who experience migraine with aura already have a higher baseline risk of ischemic stroke compared to the general population, and the estrogen component in COCs further increases this risk by promoting blood clot formation 1.
- The combination of these two risk factors can lead to a significantly higher stroke risk compared to women without migraines, with an estimated 4 additional ischemic stroke events attributable to migraine with aura per 10,000 women per year 1.
- This contraindication applies to all estrogen-containing contraceptives, regardless of estrogen dose, and is particularly important in women with additional stroke risk factors such as smoking, hypertension, or age over 35.
- For these patients, alternative contraceptive options that don't increase stroke risk include progestin-only methods (mini-pills, implants, injections), intrauterine devices (hormonal or copper), or barrier methods, as recommended in the diagnosis and management of migraine in ten steps 1.
Pathophysiology
The pathophysiology involves estrogen's prothrombotic effects, which enhance platelet aggregation and increase coagulation factors, while the neurological events during migraine with aura may involve temporary blood vessel changes that, when combined with increased clotting tendency, create favorable conditions for stroke development 1.
Clinical Implications
The use of COCs in women with migraine with aura is contraindicated due to the increased risk of stroke, and alternative contraceptive options should be considered to minimize this risk 1.
From the Research
Contraindication for COC in Women with Migraine with Aura
The contraindication for Combined Oral Contraceptives (COCs) in women with a history of migraine with aura is primarily due to the increased risk of ischemic stroke. Key points to consider include:
- The use of COCs in women with migraine with aura has been associated with a higher risk of ischemic stroke compared to those without aura 2, 3.
- Studies have shown that the risk of stroke is higher in women with migraine who use COCs, with some studies suggesting a two- to fourfold increased risk 3, 4.
- The risk of stroke is also influenced by the dose of estrogen in the COC, with higher doses (≥30 μg) associated with a greater risk of stroke 5.
- Women with migraine with aura may have a greater thrombotic risk than those without aura, which further increases the risk of stroke when using COCs 2.
Mechanism of Increased Risk
The exact mechanism of the increased risk of stroke in women with migraine with aura who use COCs is not fully understood. However, it is thought that the combination of estrogen and migraine may lead to an increased risk of thrombosis and stroke 6, 3. Additionally, women with migraine with aura may have underlying vascular risk factors that increase their susceptibility to stroke 2.
Alternative Contraceptive Options
For women with migraine with aura, alternative contraceptive options such as progestin-only pills (POPs) may be considered 6. These options may have a lower risk of stroke and thrombosis compared to COCs, although more research is needed to fully understand their safety and efficacy in this population.