How do you counsel patients interested in estrogen containing oral contraceptives who have migraine with aura?

Outside of patients whose attacks are suggestive of hemiplegic migraine, I do not typically avoid the use of estrogen-containing OCPs.

While it is my understanding that a number of international organizations and many neurologists (as well as Ob/Gyn) recommend their avoidance, there are several review articles (including AAN Continuum, Aug 2018) that delve into the weakness of the data that underpins this recommendation.

1. Studies that suggested the risk of stroke/thrombosis used estrogen doses significantly higher than those in modern OCPs.
2. Definition of aura and stroke were inconsistent in many studies. Not all studies required imaging. We know that aura symptoms can be stroke-like and that some patients have punctate nonspecific white mat...

I typically educate (and document) the possibility of stroke from this combination and counsel on using low or no estrogen OCPs as much as possible. I also make sure to ask (and document) about their tobacco use, as this increases the risk significantly of OCP use with migraine + aura.

Hormonal therapies for contraception, PCOS, endometriosis, menorrhagia, dysmenorrhea, menopause, etc., do not fit a one-size-fits-all paradigm. For some women, IUDs or implants are not a good solution. For others, estrogens are difficult to tolerate, and for others, progesterone is difficult to tolerate. If these differences in women are ignored, our patients may be left feeling like no one is listening and that the medical community has failed them. Please take all of these things into consideration when counseling migraine patients on hormonal therapies.

There are a few different things that I would take a look at, such as how well the migraine with aura is controlled, and what estrogen-containing oral contraceptive is needed for. If it is pregnancy prevention, I would consider trying something different but if it is for a medical condition, then I would consider using it.

The studies done used large doses of estrogen and there is less evidence that low doses still have the same risk of stroke. If the estrogen is needed for endometriosis or PCOS, then I may consider it and watch closely. The American Headache Society takes an individual approach to this situation.

While numerous responders have stated practices to avoid combined OCPs, none have made a clear argument based on reliable data and physiology to justify the position. Can someone in the camp who strongly avoids them please try to lay out the strongest argument for that position to help facilitate a more productive discussion?

When you have a migraine, whether it is with or without aura, episodic or chronic, it is not a good idea to use estrogen-containing birth control and there is also no need, given the availability of progestin-only contraceptives. Estrogens are bad for headaches in general and for migraine in particular and they are better avoided, I think, by everybody but especially when you're prone to headaches already.

I strongly advise them against the use of oral contraceptives since there are better contraception methods.

I suggest to them:

1. The contraceptive implant (Nexplanon) which is a small flexible plastic rod that's placed under the skin in the upper arm by a doctor or nurse. It releases the hormone progestogen into the bloodstream to prevent pregnancy and lasts for 3 years.
2. A hormonal progestin intrauterine device (IUD) that can provide long-term birth control. In addition to preventing pregnancy, many people use hormonal IUDs to help with period problems. Hormonal IUDs can cut down on cramps and make periods way lighter. Hormonal IUDs can also help treat the symptoms of things like endometriosis and PCOS.