Migraines and Hormonal Contraception: Controversies and Options

By: Anna Camille Moreno, DO NCMP • Posted on October 24, 2017 • Updated March 09, 2021

There continues to be confusion and hesitation among physicians and their female patients when prescribing combined hormonal contraceptives (CHCs) in the setting of migraine with aura.

Migraines can occur with or without an aura. An aura is a sensation, neurologic symptoms preceding the headache such as visual changes like shimmering lights, zigzagging lines or even blind spots in the vision. Almost half of all women have migraines and many of those women have auras.

Why are Women Prescribed Combined Hormonal Contraceptives?

A majority of women are prescribed CHCs because of the following reasons:

• Birth control
• Regulation of menstrual cycles in the setting of abnormal uterine bleeding, dysmenorrhea, endometriosis
• Acne control
• Mood control in Premenstrual Syndrome/Premenstrual Dysphoric Disorder PMS/PMDD
• Prevention and management of ovarian cysts
• Prevention and treatment of menstrual-related migraines

The concern about using CHC in women with migraine aura involves the potential increased risk of stroke. Some physicians have followed guidelines for use of CHCs by guidelines that originated in the 1960s and 1970s during the era of high dose contraceptive use!

What do the old contraceptive guidelines say about using prescribed CHC for migraines?

1. Some guidelines restrict the use of combined hormonal contraceptives in migraines with aura, but NOT in migraines without aura due to the associated two-fold increased risk of ischemic stroke and the four-fold increased risk of thrombotic stroke. (1)
2. A practice bulletin from the American College of Obstetrics and Gynecology in 2010 noted that healthcare providers should consider intrauterine devices, progestin-only options, and non-estrogen methods in women who have migraines with focal neurological signs, women who smoke, and women age 35 or older. (2)
3. Women who are over the age of 35 and smoke should NOT use CHC.
4. Current guidelines advise against giving oral contraceptives to women with a history of deep vein thrombosis (blood clot in the leg), myocardial infarction (heart attack), stroke, or hypertension (elevated blood pressure).

What does the evidence say: Is it is safe to let migraine patients take oral contraceptives?

• Combined hormonal contraceptives are associated with risk of ischemic stroke but this risk is dose-dependent.
• Stroke risk is NOT significantly increased in today’s ultra-low-dose formulations containing less than 20 micrograms of ethinyl estradiol (estrogen) in healthy nonsmokers.
• Stroke risk is impacted by the estrogen content of the CHC and by factors such as high blood pressure, smoking, and aura frequency.
  • High concentrations of estrogen are associated with increased frequency of aura.
  • Low concentrations of estrogen are unlikely to be associated with aura.
• Large drops in estrogen levels (prior to your menstruation) precipitates migraine attacks-> this is called menstrual-related migraines.

Should you take hormones to help with headaches?

Ask your women's health physician or migraine specialist if you meet at least 2 of the following 4 characteristics (below) to diagnose migraine with aura based on the International Classification of Headache Disorders:

1. 1 aura symptom, spreading gradually over 5 minutes, or 2 or more aura symptoms occurring in succession, or both.
2. Each aura symptom lasting 5 to 60 minutes.
3. Aura followed by the onset of headaches within 60 minutes.
4. At least 1 aura symptom is unilateral.
5. Visual blurring, floaters, or split-second flashes are not aura.

Ask your physician about what defines an “aura” (3):

1. Fully reversible visual symptoms including positive features (flickering lights, spots or lines) and/or negative features (loss of vision).
2. Fully reversible sensory symptoms including positive features (pins and needles) and/or negative features (numbness).
3. Fully reversible dysphasic speech disturbance.

Assess the risks and benefits of taking CHCs with your healthcare provider

Your provider must screen you for underlying risk factors that could put you at increased risk of stroke:

1. Over the age of 35 and with a history of smoking
2. Clotting disorder or history of blood clots such as deep venous thrombosis
3. Your physician must counsel you to report any new onset aura symptoms or changes in cardiovascular risk status.
4. Your doctor should monitor your migraine pattern at follow-up visits and if the regimen has helped in terms of migraine frequency or severity.

If you have a history of migraine with aura, evaluate your purpose of taking CHCs:

• If the sole purpose is for birth control/contraception, consider intrauterine devices (link to Dr Simpson's IUD column), progestin-only options, and non-estrogen methods.
• If the sole purpose is for other health reasons such as those stated in the first paragraph, consider a low-dose formulation after collaborating with your provider about your risk factors for stroke.
• AND take it continuously without cycling and avoid formulations with dose fluctuations such as triphasic combinations. Women with menstrual disorders, women with acne, PMDD and perimenopausal symptoms even with migraine many times do very well with low dose continuous CHC.

Take-Home Message

• Despite what you or your physician may have heard, combined hormonal contraceptives are NOT contraindicated for most women with migraine with aura!
• Current low-dose formulations are considerably safer than high-dose options but are not entirely without risk.
• Close collaboration among all treating health care providers is essential in caring for this large population of women migraine patients who need or want CHC.

Be Strong. Be Healthy. Be in Charge!

- Anna Camille Moreno, DO NCMP

References

1. Cleveland Clinic Journal of Medicine. 2017 August;84(8):631-638, et al. “Combined Hormonal Contraceptives and Migraine: An Update on the Evidence.” Cleveland Clinic Journal of Medicine, 15 Aug. 2017.
2. ACOG Practice Bulletin No. 110: noncontraceptive used of hormonal contraceptives. Obstet Gynecol 2010; 115:206-218.
3. Headache Classification Committee of the International Headache Society (HIS). The international classification of headache disorders, 3rd edition (beta version). Cephalgia 2013; 33:629-808.

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