Contraceptive Pearl: Headaches and Hormonal Contraception

Stroke occurs rarely among healthy young people: about six times per year per 100,000 women. Patients with migraine headaches have a higher risk of stroke. Migraine with aura raises the risk more, and estrogen-containing contraceptives raise the risk of stroke even further: stroke occurs about 30 times per year per 100,000 women who have migraine with aura and take combination birth control pills. Even young people with multiple risk factors rarely have strokes. However, given the many progestin-only methods available, estrogen just isn’t worth the extra risk. The Center for Disease Control and Prevention advises us that patients with a history of migraine with aura cannot use estrogen-containing birth control methods.

How do we define aura? Aura = focal neurological symptoms that occur before or at the onset of a migraine. Visual changes (such as flashing lights) are the most common type of aura. Nausea, photophobia, fatigue, irritability, and other non-focal/non-neurological premonitory symptoms don’t count as aura. This distinction matters because it determines eligibility for estrogen-containing birth control products, including the pill, patch, and ring.

Here’s the bottom line: patients who have a history of migraine with aura cannot use combination birth control pills, patch, or ring. If they have other cardiovascular risk factors (such as smoking, hypertension, diabetes, or strong family history), even patients who have migraines without aura should avoid estrogen. However, these patients can safely use a progestin-only method.

Helpful Resources

Medical Eligibility for Initiating Contraception: Absolute and Relative Contraindications

Your Birth Control Options Fact Sheet 


Edlow AG, Bartz D. Hormonal contraceptive options for women with headaches: a review of the evidence. Reviews in Obstetrics and Gynecology. 2010; 3(2): 55-65

Champaloux SW et. al. Use of combined hormonal contraceptives among women with migraines and risk of ischemic stroke. American Journal of Obstetrics & Gynecology. 2016 Dec 26. doi: 10.1016/j.agog.2016.12.019


The Reproductive Health Access Project does not accept funding from pharmaceutical companies. We do not promote specific brands of medication or contraception. The information in the Contraceptive Pearls is unbiased, based on science alone.