QUESTION:
I know that migraine with aura is a Category 4 contraindication to estrogen-containing contraception, but I have a few nuanced questions about that, which have come up in my clinical practice:
1. What if a person has auras but has never had a migraine?
2. What if the person’s migraines are menstrual migraines with aura?
3. What if they had a migraine with aura over 5 years ago and never since?
Are you a health care provider?: Yes
ANSWER:
Thank you for these nuanced questions. The easy answer is to say combination hormonal contraception (CHC) – with estrogen – is contraindicated when a patient has aura and all other contraceptive options have been offered or tried and rejected.
If you opt to explore beyond the absolute contraindications, you have to consider the patient’s overall risk of stroke, which is the concern when combining estrogen and migraines. Estrogen alone and migraine alone both increase the risk of ischemic stroke and when combined, the risk increases.
A systematic review found a 2-4 increased risk of stroke in people with migraines. One of the included studies specifically noted a higher risk when aura were present.
General note: If someone has other risk factors for stroke in addition to migraines, such as age over 35, hypertension, smoking, obesity, family history, I would avoid estrogen. I like to remind people of the MEC category “Multiple risk factor for atherosclerotic heart disease” because it’s a good reminder to weigh all risks while making a clinical decision.
If a person has auras without migraine, I would want that person evaluated by a neurologist to understand what their condition is. If that is not possible, I would err on the side of caution and avoid estrogen until I understood what they have. Over my years of practice, my impression has been that neurologists are a little more willing to prescribe CHC. This 2021 paper by the American Headache Society explains the approach to this topic from their perspective.
CHC is contraindicated in people who have migraines with aura (of any kind – even menstrual), although they can be put on progestin-only contraception to suppress their cycles and fluctuating endogenous hormone levels which may help their migraines. I have encountered people with a history of menstrual migraines with aura who have fewer or no migraines when they take continuous COC and skip their cycles. They should not be on pills and yet their migraines improve on pills. Again, depending on age and other risk factors, I have refilled prescriptions for people who have insisted they want to continue their pills because they feel better on them, if they are young, otherwise healthy and nonsmoking, and not currently experiencing aura because they are already on pills. But I would not start a new prescription and I would counsel that this is not recommended, explaining the increased risk of stroke. The safest approach is to encourage a method that is tolerable and not contraindicated, such as an IUD or progestin-only contraception. According to the American Headache Society “If a woman with uncomplicated visual aura is put on COCs, she needs to be advised to report any worsening of her auras. They should be counseled to report any new onset aura symptoms or changes in her cardiovascular risk. New-onset aura or worsening of an underlying aura condition may necessitate stopping the COC and instituting appropriate evaluation.” I would add that the patient needs to understand that this is not recommended and that all other options for safe contraception have been explored.
This question relates to the one above, exemplifying a real-world situation that can be tough to definitively know they are at increased risk of stroke today and that CHC is contraindicated. The safest approach is always to avoid estrogen. I’d want to know a lot more about their migraine history, age, other risk factors, whether they’re on migraine medication and ideally discuss this with their neurologist. Does the neurologist think they are at higher risk of stroke? If so, the contraindications for CHC apply.
Please let me know if you have additional questions,
– Dr. Z
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DISCLAIMER: This information is for educational purposes only and not intended to guide individual therapy. Answers should never substitute for consultation with a healthcare provider or counselor who can make decisions based on an individual’s history, desires, and circumstances. Always seek the advice of a clinician for any questions regarding health, medical condition, birth control method or other family planning or social issues. Under no circumstances should an individual use this information in lieu of, or to override, the judgment of a treating clinician. Dr. Zieman, or SageMed LLC, is not responsible, or liable, for errors, omissions, or any damage or loss incurred as a result of use of any birth control method or use or reliance on any material or information provided through this website.