Spotlight On: Oral Contraceptives and Migraine

Women living with migraine should speak to their healthcare provider before beginning hormonal birth control

Women experience migraine more often than men, says Dr. Huma Sheikh, Attending Neurologist at Mount Sinai School of Medicine in New York City, where she specializes in headache and vascular neurology. “Migraine is three times more common in women compared to men.” Other “studies show that women have an increased activation of parts of their brain that are involved with emotional connectivity,” says Dr. Sheikh. Another key difference for women: oral contraception.

Oral contraceptives can affect women living with migraine differently. In general, most headache specialists are comfortable with allowing a patient with migraine to take hormonal birth control, says Dr. Sheikh. In some cases, oral contraceptives can be helpful in treating migraine. However, for some women, they may elevate their risk of stroke and cardiovascular disease, depending on their personal history. In addition, women with a history of migraine with aura also appear to be at an elevated risk of deep vein thrombosis (DVT; blood clots). Estrogen-containing oral contraceptives also increase the risk of DVT, so in women who have a history of blood clots, a family history of blood clots, or previous spontaneous abortions, should be further evaluated before being placed on an estrogen-containing oral contraceptive pill.

How Oral Contraceptives Affect Migraine Symptoms

Dr. Jelena Pavlovic, Assistant Professor of Neurology at Albert Einstein College of Medicine and Headache Specialist and Attending Neurologist at Montefiore Headache Center, echoes that sentiment. “In those who had preexisting migraine, and who are then started on exogenous hormones, particularly exogenous estrogen products, their headaches can often improve with steady levels of estrogen, but sometimes they can worsen or become more frequent,” she says. “In those in whom it worsens, that should be considered as a red flag.”

Women with migraine with aura have a slightly greater risk of stroke than women without aura. “In those women, right now, the leading consensus is that we should be very careful in giving them hormonal contraceptives, because the estrogen component may increase the risk of stroke even further,” says Dr. Sheikh. Many of the studies on oral contraceptives and migraine were conducted when the estrogen dose was high, and today, these doses are much lower, so the risk may be lower now than we think, but more research is needed in women who have aura and have been exposed to low-dose estrogen.

Risk Factors

In general, for women with migraine with aura, “the decision becomes balancing benefit versus risk, using the lowest dose of monophasic oral contraceptives possible, and having a really in-depth conversation with the patient about all the potential adverse outcomes,” says Dr. Pavlovic. Additionally, women with migraine with aura who take oral hormonal contraceptives and have a personal history of smoking can further elevate their risk for stroke and cardiovascular disease. These women, Dr. Sheikh says, should stop smoking and have other risk factors, such as high blood pressure, treated appropriately.

Women with aura who use progestin as their hormonal contraceptive do not appear to have an increased risk for stroke. “There are no studies indicating that there is an increased risk of cardiovascular disease, and stroke in particular, with progesterone-containing contraception,” says Dr. Pavlovic.

For women who develop migraine for the first time after starting an oral contraceptive with estrogen, it’s important to see your healthcare provider for next steps. “I would take that patient off oral contraceptives, and probably switch them to a progesterone-containing contraceptive, and avoid exogenous estrogen,” Dr. Pavlovic says. “I would also work them up further with imaging, including an MRI of the brain and brain/neck blood vessels, and keep a watchful eye on them for at least 6-12 months.”

If you are living with migraine and have questions about the right oral contraceptive for you, contact your primary care provider to go over your options, then schedule an appointment with a headache specialist. To find a headache specialist near you, use our Find Help tool. You can also visit the AMF’s Resource Library to view a wealth of information on treatment options, women with migraine and more.