Contraception with migraine with aura
The case
A 28-year-old woman asks her GP for contraception. She has migraine with aura two to three times a month, treated with sumatriptan. She smokes 8 cigarettes a day. Blood pressure is 128/82 mmHg. She has no history of venous thromboembolism, no personal or family history of stroke and no diabetes. Her cycles are regular and her last cervical screening was normal. She asks specifically about the combined oral contraceptive pill because a friend uses it without problems. Which of the following most accurately reflects the appropriate contraceptive advice?
Options
- AAvoid the combined pill; offer a progestogen-only method
- BThe combined pill is safe, so prescribe it
- CSmoking is the only concern, so the pill is safe if she quits
- DA low-dose pill removes the stroke risk
- EThe pill is only unsafe in smokers over 35
Think it through before you read on. Which single option is best, and why are the other four wrong?
Show the answer and explanation
Answer
A. Avoid the combined pill; offer a progestogen-only method
Why this is the right answer
Migraine with aura is an absolute contraindication to all oestrogen-containing contraception: the combined pill, the patch and the vaginal ring. In the World Health Organization and UK Medical Eligibility Criteria, which Australian guidance follows, it is Category 4, meaning the risk is unacceptable. This applies at any age, whether or not the woman smokes.
The reason is stroke. Migraine with aura on its own roughly doubles the risk of ischaemic stroke in young women. Oestrogen adds a prothrombotic effect and multiplies that risk further. Smoking adds again. The absolute risk is still small, but there is no need to accept it, because equally effective alternatives exist.
Progestogen-only methods do not increase stroke risk and are all suitable: the etonogestrel implant, the levonorgestrel intrauterine device, the depot medroxyprogesterone injection and the progestogen-only pill. Long-acting reversible contraception (the implant or an IUD) is the most effective and is recommended first-line in Australia for women who want reliable contraception. A copper IUD is also an option.
This is also an opportunity for smoking cessation advice, which reduces her stroke and cardiovascular risk independently of contraception.
Migraine without aura is different: the combined pill can be used in women under 35 (Category 2), but it should be stopped if aura develops.
Why the other options are wrong
- B
Migraine with aura is Category 4 for oestrogen; prescribing the combined pill is unsafe.
- C
Quitting smoking does not remove the aura-related contraindication.
- D
No oestrogen dose is considered safe with migraine with aura.
- E
The age-35-and-smoking rule is a separate contraindication; aura excludes oestrogen at any age.
High-yield takeaway
Migraine with aura means no oestrogen at any age: offer an implant, an IUD, the injection or a progestogen-only pill instead.
Reference: UK Medical Eligibility Criteria for Contraceptive Use (FSRH), as adopted in Australian practice (RANZCOG, Family Planning Alliance Australia) (2016 (amended 2019))
Common questions
Can a woman with migraine with aura ever take the combined pill?
No. Migraine with aura is an absolute contraindication to all oestrogen-containing contraception at any age.
What about migraine without aura?
The combined pill can be used in women under 35 without other risk factors, but must be stopped if aura develops.
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