For a woman with migraine with aura, is estrogen‑containing hormonal contraception contraindicated?

Migraine with Aura: Absolute Contraindication to Estrogen-Containing Contraceptives

Estrogen-containing combined hormonal contraceptives (pills, patches, vaginal rings) are absolutely contraindicated in women with migraine with aura due to a 7-fold increased risk of ischemic stroke. 1, 2

Why Estrogen is Contraindicated

• Migraine with aura independently increases ischemic stroke risk approximately 2.5-fold compared to women without migraine. 2
• Adding estrogen-containing contraceptives amplifies this risk dramatically, with odds ratios ranging from 2.08 to 16.9 for ischemic stroke. 2, 3
• Women with migraine with aura who use estrogen-containing contraceptives face a 7-fold higher risk of ischemic stroke (RR 7.02; 95% CI 1.51–32.68). 2
• The 2024 American Heart Association/American Stroke Association guidelines explicitly recommend against estrogen-containing contraceptives in individuals with migraine with aura. 1
• The 2010 CDC Medical Eligibility Criteria assigns a Category 4 (absolute contraindication) to combined hormonal contraceptives in women with migraine with aura at any age. 1

Dose-Response Relationship

• A direct, linear relationship exists between estrogen dose and stroke risk—every 10 μg increase in ethinyl estradiol raises stroke risk (OR 1.19; 95% CI 1.16–1.23). 1
• Formulations with <50 μg estrogen carry lower risk (RR 2.08) compared to higher-dose preparations (RR 4.53), but all estrogen-containing contraceptives remain contraindicated in migraine with aura. 1

Safe, Highly Effective Alternatives

First-Line Long-Acting Reversible Contraceptives (LARCs)

Levonorgestrel Intrauterine System (LNG-IUD):

• Provides >99% contraceptive effectiveness without increasing stroke risk. 2
• No contraindication for migraine with aura per CDC guidelines. 2
• May reduce menstrual bleeding, which benefits women with heavy periods. 2

Etonogestrel Subdermal Implant:

• Offers >99% contraceptive effectiveness without estrogen-related stroke risk. 2
• Safe for women with migraine with aura. 2
• Requires backup contraception for 7 days if inserted >5 days after menses onset. 2

Copper Intrauterine Device (Cu-IUD):

• Non-hormonal option with >99% effectiveness and zero stroke risk. 2
• No migraine-with-aura contraindication. 2
• No backup contraception required regardless of cycle timing. 2
• May initially increase menstrual bleeding and cramping. 2

Second-Line Options

Progestin-Only Pills (POPs):

• Norethindrone or drospirenone formulations carry no stroke risk in migraine-with-aura patients. 2, 4
• Effectiveness is lower (≈90%) than LARCs due to strict daily timing requirements. 1, 2
• Norethindrone/norgestrel: backup contraception for 2 days if started >5 days after menses. 2
• Drospirenone: backup contraception for 7 days if started >1 day after menses. 2

Depot Medroxyprogesterone Acetate (DMPA):

• Does not increase stroke risk in women with migraine with aura. 2
• Conditionally discouraged in patients with osteoporosis risk factors due to potential 7.5% bone mineral density decline over two years. 2
• Requires backup contraception for 7 days if initiated >7 days after menses. 2

Critical Counseling Points

• Tobacco use must be absolutely prohibited—smoking combined with migraine with aura creates catastrophic stroke risk even without hormonal contraception. 2
• Screen for and aggressively manage hypertension, another modifiable stroke risk factor. 1, 2
• The 2024 AHA/ASA guidelines recommend shared decision-making to balance contraceptive stroke risk against pregnancy-related stroke risk (30 per 100,000 pregnancies). 1
• Irregular bleeding is the most common side effect of progestin-only methods; upfront counseling improves adherence. 2
• For bothersome bleeding with LNG-IUD or implant, prescribe NSAIDs for 5–7 days. 2
• For heavy or prolonged bleeding with implant, consider brief low-dose estrogen (10–20 days) or tranexamic acid for 5 days. 2

Common Pitfall to Avoid

• Do not attempt to "individualize" estrogen-containing contraceptive use based on low absolute stroke risk or newer low-dose formulations. 5, 3 While some research suggests absolute risk remains low and questions whether guidelines are too strict, the 2024 AHA/ASA guidelines—the highest-quality, most recent evidence—maintain an absolute contraindication. 1 The potential for catastrophic morbidity (ischemic stroke in a young woman) outweighs any theoretical benefit of estrogen-containing contraception when highly effective, stroke-safe alternatives exist. 2