No, combination birth control is contraindicated in women with ocular migraines (migraine with aura)
Combined hormonal contraceptives containing estrogen are absolutely contraindicated in women with migraine with aura, including ocular migraines, due to a significantly elevated risk of ischemic stroke. 1
Understanding the Stroke Risk
The combination of migraine with aura and estrogen-containing contraceptives creates a multiplicative stroke risk:
- Migraine with aura alone increases ischemic stroke risk 2.5-fold (RR 2.51; 95% CI 1.52-4.14) 1
- Estrogen-containing contraceptives alone increase stroke risk approximately 2-fold (RR 1.6-1.7) 1
- When combined, the risk increases 7-fold (RR 7.02; 95% CI 1.51-32.68) compared to women without migraine who don't use contraceptives 1, 2
- Women with migraine with aura taking estrogen contraceptives have odds ratios ranging from 2.08 to 16.9 for ischemic stroke 1
Additional Risk Factors That Worsen the Situation
If you have any of these additional risk factors, the stroke risk becomes even more dangerous:
- Smoking creates catastrophic risk (RR 9.03; 95% CI 4.22-19.34) when combined with migraine and estrogen 1, 2
- Age over 35 years significantly amplifies risk (RR 3.65; 95% CI 2.21-6.04 for women under 45) 1, 2
- Hypertension increases myocardial infarction risk 6-68 fold and ischemic stroke risk 3.1-14.5 fold in women taking combined contraceptives 1
- High migraine frequency (more than weekly attacks) further increases stroke risk (HR 4.25; 95% CI 1.36-13.29) 1, 2
Safe Contraceptive Alternatives
Progestogen-only methods are the recommended alternative because they do not carry the same stroke risk as estrogen-containing contraceptives:
- Progestogen-only pills show no increased risk of myocardial infarction (RR 0.98; 95% CI 0.66-1.47) or stroke (RR 1.02; 95% CI 0.72-1.44) 1
- Desogestrel 75μg progestogen-only pill may actually reduce migraine frequency and intensity in both migraine with and without aura 3
- Other progestogen-only options include implants, injectables (DMPA), and levonorgestrel IUDs, all of which are safe in migraine with aura 1, 3
- Barrier methods (condoms, diaphragm) carry no stroke risk and are classified as Category 1 (no restrictions) 1
Critical Clinical Pitfalls to Avoid
- Do not assume "ocular migraine" means migraine without aura - ocular migraines typically involve visual aura symptoms (flashing lights, zigzag lines, temporary vision loss) and should be treated as migraine with aura 1
- Do not prescribe combined contraceptives even if aura symptoms seem "mild" - the guideline contraindication applies regardless of aura severity 1
- Do not continue combined contraceptives if new aura symptoms develop - women with migraine without aura who develop aura while taking combined contraceptives must discontinue them immediately 4, 5
- Do not rely on lower-dose estrogen formulations as "safer" - even formulations with <50μg estrogen carry increased stroke risk in migraine with aura 1, 4, 6
What If Combined Contraceptives Are Already Being Used?
Stop the combined hormonal contraceptive immediately and transition to a progestogen-only method 1. The absolute contraindication applies regardless of how long the medication has been used without problems - stroke risk remains elevated throughout use 1, 2.