Do oral contraceptive pills (OCPs) cause headaches?

Oral Contraceptive Pills and Headaches

Yes, oral contraceptive pills (OCPs) can cause headaches, particularly combined hormonal contraceptives that contain estrogen. 1

Types of OCP-Related Headaches

OCPs can cause two main types of headache:

1. Exogenous hormone-induced headache:

   • Occurs during active use of combined hormonal contraceptives
   • More common in women with pre-existing migraine, especially migraine with aura
   • Usually appears within the first few months of starting OCPs 2

2. Estrogen-withdrawal headache:

   • Occurs during the hormone-free interval (placebo week)
   • Appears within the first 5 days after stopping the active pills
   • Usually resolves within 3 days 2

Risk Factors and Mechanisms

• The estrogen component in combined OCPs is primarily responsible for headache symptoms 1
• Higher doses of ethinyl estradiol are associated with greater risk of headache 1
• Women with pre-existing migraine are more susceptible to OCP-related headaches 3
• Headaches typically improve after the first few months of use as the body adapts to hormone levels 4

Management Strategies

For women experiencing OCP-related headaches:

1. For exogenous hormone-induced headaches:

   • Switch to a lower-dose estrogen formulation (≤20 μg ethinyl estradiol) 1
   • Consider progestin-only pills which do not typically cause headaches 4

2. For estrogen-withdrawal headaches:

   • Eliminate or reduce the hormone-free interval using extended or continuous regimens 5
   • Use low-dose estrogen supplementation during the pill-free week 4
   • Switch to a progestin-only method 4

Special Considerations

• Migraine with aura: Combined hormonal contraceptives are contraindicated due to increased stroke risk 3
• Migraine without aura: Combined hormonal contraceptives can be used with caution, but should be discontinued if headaches worsen 6
• Hypertension: Women with severe uncontrolled hypertension (≥160/100 mmHg) should avoid combined OCPs as they may further increase blood pressure and stroke risk 1

Monitoring Recommendations

• Schedule a follow-up visit 1-3 months after initiating OCPs to assess for adverse effects including headaches 1
• Monitor for warning signs that require discontinuation:
  • Development of aura symptoms
  • Significant worsening of pre-existing headache pattern
  • New onset of severe headache

Alternative Options

For women who cannot tolerate combined OCPs due to headaches:

• Progestin-only pills (POPs)
• Long-acting reversible contraceptives (IUDs, implants)
• Non-hormonal methods (copper IUD, barrier methods)

The evidence clearly shows that while OCPs can trigger or worsen headaches in some women, the effect varies based on the type of contraceptive, dosage, and individual susceptibility. Progestin-only methods are generally better tolerated in women prone to headaches.