Migraine without aura may raise stroke risk in combined hormonal contraceptive users

Key takeaways:

• Combined hormonal contraceptive use is restricted in women with migraine with aura due to stroke risk.
• A recent study found an increased risk in women with migraine without aura, not those with aura.

Among combined hormonal contraceptive users, those with a history of migraine without aura had a significantly increased risk for ischemic stroke compared with those without a history of migraine, data show.

In contrast, women with migraine with aura had no significant increased risk for stroke, which conflicts with guidelines that “discourage the use of combined hormonal contraceptives (CHC) in women who experience migraine with aura due to concerns about ischemic stroke,” Pelin Batur, MD, a professor of OB/GYN and reproductive biology at the OB/GYN & Women’s Health Institute at Cleveland Clinic, and colleagues wrote in Headache.

Speaking at the 2023 ACP Internal Medicine Meeting, Batur said “there's a real contraindication, according to the CDC, if they have aura.”

Because one-third of patients with migraine have accompanying aura, Batur and colleagues wrote in their study that it limits women’s choices for CHC use.

“Thus, it is of utmost importance to know if there are ways to prescribe CHCs that may mitigate these risks,” they wrote.

The researchers conducted a case-control analysis to examine the associations between stroke risk and migraine history as well as ethinyl estradiol (EE) dose. The study included 203,853 women who had a mean age of 35 years and used CHCs between Jan. 1, 2010, to Dec. 31, 2019.

Overall, 127 women had confirmed cases of stroke and were placed into the case cohort, while 635 women were placed into a control cohort.

Batur and colleagues found that a higher proportion of patients in the case cohort had a diagnosis of migraine (26.8%) compared with those in the control cohort (17.3%).

Patients who received an EE dose of 30 g or greater had an increased risk for stroke compared with those prescribed less than 30 g EE (OR = 1.52; 95% CI, 1.02-2.26), according to the researchers.

Additionally, patients with a history of migraine had twice the odds of stroke (OR = 2; 95% CI, 1.27-3.17) compared with those who had no history of migraine. However, upon further analysis, the researchers found that stroke risk was only significant in those with migraine without aura (OR = 2.35; 95% CI, 1.32-4.2), not among those with migraine with aura, when compared with patients with no migraine history.

“I think there’s a conversation that’s developing nowadays,” Batur said at ACP. “Some of the newer generations of headache specialists are really on top of this.”

When considering estrogen-containing contraceptives in patients with a history of migraine, Batur said “You do want to make sure that you consider the other options and not only talk to your patient about the risks but document them.”

“Remember that stroke is rare, but it can be life-altering for a young woman, so it’s important to talk about,” she said. “If you use an estrogen-containing product, you can probably minimize risks and symptoms with 25 mg or less.”

References:

• Batur P. A complete contraception workshop: What’s new? Presented at: ACP Internal Medicine Meeting; April 27-29, 2023.
• Batur P, et al. Headache. 2023;doi:10.1111/head.14473.