Stroke occurs rarely among healthy young women: about 6 times per year per 100,000 women. Women 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 women with multiple risk factors rarely have strokes. However, given the many progestin-only methods available, estrogen just isn’t worth the extra risk. The World Health Organization advises us that women who have migraine with aura cannot use estrogen-containing birth control pills.

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 combination birth control pills.

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

We appreciate your feedback! Please write to us at pearls@reproductiveaccess.org with any questions, comments or additional resources to add to our list.

Helpful Resources

Medical Eligibility for Initiating Contraception: Absolute and Relative Contraindications

Sources

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

Jody Steinauer. An evidence-based approach to contraception in women with medical disease. The Association of Reproductive Health Professionals.

Pharma-free

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.