What are the recommendations for using Oral Contraceptive Pills (OCP) in patients with migraine with aura?

Oral Contraceptive Pills in Migraine with Aura

Women with migraine with aura should avoid combined hormonal contraceptives due to significantly increased stroke risk, and should be counseled to use alternative contraceptive methods. 1, 2

Risk Assessment and Rationale

The evidence clearly demonstrates that combined hormonal contraceptives significantly increase stroke risk in women with migraine with aura:

• Meta-analyses show that oral contraceptive use in women with migraine with aura increases ischemic stroke risk by 7-fold (RR 7.02; 95% CI, 1.51–32.68) 1
• Women with migraine with aura have an independent increased risk of ischemic stroke (RR 2.16; 95% CI, 1.53–3.03) compared to those without aura 1
• The FDA explicitly lists "headaches with focal neurological symptoms" (which includes migraine with aura) as a contraindication to combined oral contraceptives 3
• The American Heart Association/American Stroke Association guidelines recommend against using combined hormonal contraceptives in women with migraine with aura 2

Contraceptive Options for Women with Migraine with Aura

Recommended Options

1. Progestogen-only methods are safe for all migraine patients, including those with aura 2, 4:

   • Progestogen-only pills
   • Levonorgestrel intrauterine device
   • Etonogestrel implant
   • Depot medroxyprogesterone acetate injections

2. Non-hormonal methods:

   • Copper IUD
   • Barrier methods (condoms, diaphragms)
   • Fertility awareness methods

Evidence for Progestogen-Only Methods

A prospective diary-based study demonstrated that desogestrel-containing progestogen-only pills not only were safe but also showed beneficial effects on migraine with aura symptoms 4:

• Significant reduction in migraine attacks after 6 months
• Reduced duration of visual aura (from 16.3±9.5 to 11.4±5.6 min)
• Reduced total duration of neurological symptoms (from 33.6±23.3 to 18.6±18.0 min)

Risk Stratification

The risk of stroke is particularly elevated when migraine with aura is combined with:

1. Age ≥35 years (RR 3.65; 95% CI, 2.21–6.04) 1
2. Smoking (RR 9.03; 95% CI, 4.22–19.34) 1
3. Other cardiovascular risk factors such as:
   • Hypertension
   • Hyperlipidemia
   • Diabetes
   • Obesity

Management Algorithm

1. For women with confirmed migraine with aura:

   • Discontinue combined hormonal contraceptives if currently using
   • Recommend progestogen-only or non-hormonal contraceptive methods
   • Document the discussion of stroke risk in the medical record

2. For women with migraine without aura:

   • Can use combined hormonal contraceptives if no other risk factors
   • Monitor for development of aura symptoms
   • Discontinue combined hormonal contraceptives immediately if aura symptoms develop 2

3. Warning signs requiring immediate discontinuation of combined hormonal contraceptives:

   • Development of aura in previously aura-free migraine
   • Worsening headache pattern
   • New focal neurological symptoms 2

Common Pitfalls and Caveats

1. Failure to distinguish between migraine with and without aura

   • Careful history taking is essential to identify aura symptoms
   • Aura typically presents as visual disturbances (flashing lights, zigzag lines, scotoma) but can also include sensory, speech, or motor symptoms

2. Underestimating stroke risk

   • While absolute risk of stroke is low in young, healthy women, the relative risk increase with combined factors is substantial
   • One study found odds ratio of 6.1 (CI 3.1 to 12.1) for stroke in migraine with aura vs 1.8 (CI 1.1 to 2.9) in migraine without aura 5

3. Overreliance on low-dose formulations

   • Even modern low-dose combined hormonal contraceptives carry increased risk in women with migraine with aura 6, 7
   • The risk appears to be estrogen dose-dependent, but no safe threshold has been established 5

4. Inadequate follow-up

   • Regular follow-up (every 2-3 months initially, then every 6-12 months) is necessary to monitor for changes in migraine pattern and development of aura symptoms 2

By following these evidence-based recommendations, clinicians can help women with migraine with aura make safe contraceptive choices that minimize their risk of stroke while providing effective contraception.