What is the risk of stroke in individuals with migraine with aura who are taking Oral Contraceptive Pills (OCPs)?

Risk of Stroke in Migraine with Aura and OCP Use

Women with migraine with aura who take oral contraceptive pills (OCPs) have a significantly increased risk of stroke, and alternative forms of birth control should be recommended for these patients.

Evidence on Stroke Risk

Migraine with aura is associated with an increased risk of ischemic stroke, particularly in women of childbearing age. This risk is substantially amplified when combined with OCP use:

• Meta-analyses show that migraine with aura increases stroke risk (RR 2.16; 95% CI, 1.53-3.03) compared to migraine without aura (RR 1.23; 95% CI, 0.90-1.69) 1
• The combination of migraine with aura and OCP use dramatically increases stroke risk (RR 7.02; 95% CI, 1.51-32.68) 1
• Women under 45 years with migraine with aura have particularly elevated risk (RR 3.65; 95% CI, 2.21-6.04) 1
• When migraine with aura is combined with smoking and OCP use, the risk increases even further (RR 9.03; 95% CI, 4.22-19.34) 1

Risk Stratification by Migraine Type

The risk varies significantly based on the type of migraine:

• Migraine with aura: Significantly increased stroke risk, especially with OCP use
• Migraine without aura: Less clear association with stroke risk, though some studies show increased risk with OCP use 2
• Frequency matters: Higher frequency of migraine with aura attacks (more than weekly) is associated with greater stroke risk (HR 4.25; 95% CI, 1.36-13.29) 1

Recommendations for Clinical Practice

Based on current guidelines:

1. For women with migraine with aura:

   • OCPs are contraindicated due to the significantly increased stroke risk 1
   • Alternative non-hormonal contraceptive methods should be recommended
   • If hormonal contraception is necessary, progestin-only methods may be considered

2. For women with migraine without aura:

   • Carefully evaluate for other stroke risk factors before prescribing OCPs
   • Consider lower estrogen dose formulations (<30 μg ethinyl estradiol) if OCPs are used 2
   • Monitor for development of aura symptoms and discontinue OCPs if aura develops

3. Additional risk factors requiring special attention:

   • Age >35 years
   • Smoking
   • Hypertension
   • Family history of stroke
   • Previous cardiovascular events

Common Pitfalls to Avoid

• Failure to distinguish migraine subtypes: Always determine whether aura is present, as this significantly impacts stroke risk and contraceptive recommendations
• Overlooking combined risk factors: The combination of migraine with aura, OCPs, and smoking creates a particularly dangerous risk profile
• Continuing OCPs after development of new aura symptoms: If a woman with migraine without aura develops aura while on OCPs, the OCPs should be discontinued immediately
• Ignoring migraine frequency: Higher frequency of migraine with aura attacks correlates with increased stroke risk

Algorithm for Contraceptive Decision-Making in Migraine Patients

1. Determine migraine subtype (with or without aura)
2. If migraine with aura:
   • Avoid combined hormonal contraceptives
   • Recommend non-hormonal methods (copper IUD, barrier methods)
   • Consider progestin-only methods if necessary
3. If migraine without aura:
   • Assess additional stroke risk factors
   • If no additional risk factors and age <35: Consider low-dose OCPs (<30 μg ethinyl estradiol)
   • If additional risk factors or age >35: Consider non-hormonal or progestin-only methods
4. For all migraine patients on hormonal contraception:
   • Monitor for new or changing aura symptoms
   • Educate about warning signs of stroke
   • Reassess contraceptive choice at regular intervals

The evidence strongly supports avoiding combined hormonal contraceptives in women with migraine with aura due to the substantially increased risk of stroke.