Migraine, strokes, and oral contraceptives

Researchers at the Cleveland Clinic investigated the risk of stroke associated with different estrogen doses in oral contraceptives (OCP) for individuals with migraines. The results of their study were recently published in the journal of the American Headache Society, Headache.

The overall stroke risk among OCP users in this study was low. Out of the 203,853 women aged 18-55 who used OCPs, 127 were confirmed to have had a stroke. The case group had a higher proportion of individuals diagnosed with migraines (34/127, 26.8%) compared to a control group of 635 women (109/635, 17.2%; p = 0.011). The risk of stroke was higher among those using OCPs with 30 mcg or more of estrogen compared to those using OCPs with less than 30 mcg. Having a personal history of migraines increased the likelihood of stroke compared to those without migraines. There was no significant increase in stroke risk among those with migraine with aura, but migraine without aura did increase the risk.

Interestingly, previous studies have suggested the opposite—that migraine with aura carries a higher stroke risk compared to migraine without aura. The researchers speculate that this discrepancy could be because patients with migraine with aura are rarely prescribed OCPs, and the number of such patients in this study was small.

Traditionally, young and healthy women diagnosed with migraine with aura have been advised against using estrogen contraceptives due to concerns about increased stroke risk compared to those without aura. However, the risk of unintended pregnancies should be weighed against the risk of a stroke. The authors emphasize the need for proper patient education and shared decision-making when it comes to starting contraceptives in women with a history of migraines, including those without aura. OCP formulations with less than 30 mcg of estrogen are preferred to minimize the risk of stroke.