From the Guidelines
Women with migraines with aura should not take the combined hormonal contraceptive pill due to an increased risk of stroke. The estrogen in combined pills can cause blood vessels to constrict and increase clotting factors, which may trigger or worsen migraines and significantly raise stroke risk in those who experience aura (visual disturbances, numbness, or speech changes before migraine pain) 1. For women with migraines without aura, the combined pill may be used with caution if there are no other cardiovascular risk factors like smoking, high blood pressure, or being over 35.
Key Considerations
- The risk of stroke is higher in women with migraines with aura, especially those who are younger than 45 years, smoke, or use oral contraceptives (OCs) 1.
- The estrogen component in combined oral contraceptives (COCs) can increase the risk of blood clots, which can lead to stroke or other cardiovascular events 1.
- Progestogen-only methods, such as the mini-pill (desogestrel 75mcg daily), hormonal implant (Nexplanon), hormonal IUD (Mirena, Kyleena), or the injectable (Depo-Provera), are safer alternatives for women with migraines, as they do not increase the risk of stroke 1.
Recommendations
- Women with migraines with aura should avoid using combined hormonal contraceptive pills and instead consider progestogen-only methods.
- Women with migraines without aura can use combined hormonal contraceptive pills with caution, but should be monitored for any changes in their migraine symptoms or cardiovascular risk factors.
- Any woman who develops migraines with aura while taking the combined pill should stop it immediately and use alternative contraception.
From the FDA Drug Label
The onset or exacerbation of migraine or development of headache with a new pattern which is recurrent, persistent, or severe requires discontinuation of oral contraceptives and evaluation of the cause.
The combined pill may exacerbate migraine or cause the development of a new headache pattern. If this occurs, it is recommended to discontinue oral contraceptives and evaluate the cause.
- Migraine is a potential adverse reaction associated with the use of oral contraceptives.
- The FDA drug label recommends careful evaluation and consideration of alternative contraceptive methods for women who experience migraine or headache while taking the combined pill 2.
From the Research
Combined Pill and Migraine
- The use of combined hormonal contraceptives (CHCs) in women with migraine may carry a small but significant vascular risk, especially in those with migraine with aura (MA) and additional risk factors for stroke 3.
- Guidelines recommend progestogen-only contraception as a safer alternative, as it does not seem to be associated with an increased risk of venous thromboembolism (VTE) and ischemic stroke 3.
- Studies have shown that the progestin-only pill containing desogestrel 75μg may have a positive effect on the course of both MA and migraine without aura (MO), reducing the number of days with migraine, the number of analgesics, and the intensity of associated symptoms 3, 4.
Risk of Stroke
- The use of CHCs in women with migraine may increase the risk of ischemic stroke, with some studies suggesting a two- to fourfold increased risk compared to nonuse 5, 6.
- The risk of stroke may be estrogen dose-related, with high-dose formulations having the highest risk 7, 6.
- However, the absolute risk of ischemic stroke with CHCs in women with migraine is low, and an individualized approach may be more appropriate than current guidelines 7, 6.
Progestin-Only Contraceptives
- Progestin-only contraceptives, such as the desogestrel 75μg pill, may be effective in reducing the number of migraine attacks and migraine days, as well as improving headache-related quality of life 4.
- The evidence for the effectiveness of progestin-only contraceptives in migraine treatment is low to very low quality, and further randomized trials are needed to confirm their role in migraine management 4.