For years, combined hormonal contraceptive (CHC) use has been restricted for women who have migraine with aura due to concerns about stroke risk. A new study suggests these risks may not be as clear-cut as previously thought.

Use of combined hormonal contraceptive (CHC) is complicated for people living with migraine. Many who have migraine with aura are denied CHC prescriptions because of an increased stroke risk, but the risks associated with an unintended pregnancy are often much greater. To be able to fully manage their own health care, people living with migraine need access to as many viable contraceptive options as possible. 

A new study suggests that while CHC presents an increased risk of stroke for women who have migraine with aura, this risk may not be as high as previously thought—and may depend much more on individual health factors than CHC alone. We spoke with the author of the study, Dr. Pelin Batur, Internal Medicine Specialist at the Center for Specialized Women’s Health, Cleveland Clinic. Through her work, Dr. Batur aims to give women a voice, helping them advocate for themselves to get the best treatment available.

Evaluating Stroke Risk vs. Risk of Unintended Pregnancy

Dr. Batur’s research into migraine, CHC usage and stroke risk came after years of encountering women living with migraine who visited her practice in frustration.

“I’ve had women come into my office crying,” Dr. Batur says. “They say, ‘Nobody will prescribe [CHC] to me. But when I was on it, I felt amazing and it helped my acne, it reduced my heavy bleeding and my headaches were under control. I understand there’s an increased risk of stroke, but I’m watching my blood pressure and eating healthy.’”

After looking at the existing research, Dr. Batur found that the evidence against CHC usage in people who have migraine with aura was far from conclusive. Her recently published study was motivated by a desire to more fully understand the complex risks involved in CHC use among people with migraine with aura and how this compares to other common risk factors.

“Is there really something so different about [migraine with] aura? Because that information is hard to find in the literature,” Dr. Batur says. “Part of the reason is because stroke is a rare complication, and most young women do not suffer a stroke even if they’re on the pill. When you have rare diseases, it’s hard to find good scientific answers.”

Dr. Batur considered the risks of denying a CHC prescription to women who have migraine with aura and consequently increasing the likelihood of an unintended pregnancy. “We always talk about the risks of contraceptives, but the risks of unintended pregnancy are always much, much greater,” Dr. Batur says. “Just under half of pregnancies in the United States are unintended, so it’s not a small number.”

A New Study on Migraine and CHC Stroke Risk

Ultimately, two questions framed Dr. Batur’s study: Does migraine—particularly migraine with aura—compound ischemic stroke risk in CHC users? And if so, is there a difference in stroke risks based on more commonly prescribed estrogen doses?

Prior studies have failed to consistently demonstrate an increased stroke risk in people who have migraine without aura compared to people without migraine. However, prior research has shown:

  • A two-fold stroke risk increase in people with migraine with aura
  • A six-fold increase with the use of CHC 
  • Up to a nine-fold increase when multiple risk factors like smoking and the use of CHC were present

These figures have long led to the assumption that CHC use will dramatically increase stroke risk in people living with migraine with aura. To test this, Dr. Batur and her team conducted a study involving women in the Cleveland Clinic system.

“We looked at all the women aged 18-55 [with migraine] in the Cleveland Clinic system from 2010 to 2020 who received CHC,” Dr. Batur says. “We wanted to understand what percentage of these women had something bad happen, like a stroke, and it was a very small number.” 

Stroke Risk Based on Migraine Subtype

Of the over 200,000 women whose health data was used for the study, Dr. Batur and her team identified 127 who had a confirmed stroke during the 10-year time period they examined. The research team then dug deeper into the health backgrounds of each woman, including identifying their migraine subtype. “[For example] did they have migraine with or without aura?” Dr. Batur says. “Was there some sort of increased, heightened risk in those who had migraine with aura?” 

A surprising pattern emerged: Not only was there no measurable increase in stroke risk for women using CHC who had migraine with aura—it actually appeared the opposite was true. More research will be needed to understand why this pattern exists, but these results challenge prior accepted ideas about stroke risk and CHC usage.

“It was the women who had migraine without aura that seemed to have a higher risk of stroke in our group,” Dr. Batur says. “This goes against what the [Centers for Disease Control] guidelines currently say: ‘If you don’t have aura, you can use CHC. If you do, you can’t.’ Our findings suggest that this may not be good advice.”

Estrogen Levels in CHC Medications Impact Stroke Risk

Dr. Batur and her team found one additional factor that may help doctors assess whether CHC is right for patients with migraine: the specific dosage of estrogen in a medication. The vast majority of birth control medications, including CHC, contain estrogen—and it is this ingredient that seems to have the largest impact on stroke risk.

“In our study, those who were on lower estrogen doses had a decreased stroke risk,” Dr. Batur says. “If the dosage was 30 micrograms or higher, stroke risk was increased. If women with migraine want to use an estrogen-containing pill, it would be preferable to use one with under 30 micrograms of estrogen.”

Dr. Batur’s findings suggest a significant shift from the current guidelines around migraine, CHC usage and stroke risk. However, this single study is far from conclusive, and more research is needed to better inform CHC prescription and usage in people with migraine with aura. 

“When you’re dealing with smaller numbers, there’s always a chance that there could be a flaw in the statistics,” Dr. Batur says. “Since only 127 women had confirmed stroke [in our study], you do have to take the information with a grain of salt. This is only one piece of the puzzle, and it’s by no means the end-all answer.”

Deciding Whether to Go on CHC Birth Control With Migraine

While future research will be needed to confirm and develop these findings, the study still has significant implications for women who have migraine with or without aura. The biggest takeaway from Dr. Batur’s study is that there should not be a one-size-fits-all approach to prescribing (or not prescribing) CHC to a person with migraine, with or without aura.

“[This study] is a guide for clinicians to help them listen to the patient and to help them understand the risks and benefits of CHC,” Dr. Batur says. “The big picture we want to bring forward is … don’t be so restrictive. If a patient really needs or prefers an estrogen-containing contraceptive [like CHC] to prevent pregnancy or to treat a medical condition, it should be a conversation, not an immediate denial.”

Future research will determine whether guidance changes when it comes to prescribing CHC to people with migraine, but Dr. Batur hopes this study will enable people to have more informed conversations with their doctor about their own migraine treatment.

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