In a consensus statement published in The Journal of Headache and Pain, the European Headache Federation and the European Society of Contraception and Reproductive Health cautioned against the use of hormonal contraceptives in women with migraine — while acknowledging the low quality of supporting evidence — as these medications may be associated with an increased risk for ischemic stroke.

A panel of multidisciplinary specialists in migraine, cardiovascular risks, and hormonal contraception systematically reviewed 6 studies to determine the association between migraine, stroke, and hormonal contraception. A modified Delphi method was used to develop a consensus statement regarding the use of contraception in women with migraine.

Based on the studies, the estimated risk for ischemic stroke in women age 20 to 44 not taking hormonal contraception and not experiencing migraine was 2.5/100,000 per year. This risk was increased to 5.9 and 4.0/100,000 per year by the presence of migraine with and without aura, respectively. Hormonal contraceptive use in women with migraine with and without aura was found to increase the risk for ischemic stroke to 36.9 and 25.4/100,000 per year, respectively.

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Based on these data, the consensus panel strongly recommended that women seeking hormonal contraception should be evaluated for the presence of migraine with a dedicated, easy-to-use diagnostic tool.

The panel also encouraged clinicians to consider the risk level associated with different types of hormonal contraception. No-risk products such as progestogen-only contraceptives were recommended in women with migraine, while the panel recommended that clinicians avoid prescribing high-risk products such as combined oral contraceptives containing >35 μg ethinylestradiol in patients with migraine.

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In an interview with Clinical Pain Advisor, Simona Sacco, MD, associate professor of neurology at the University of L’Aquila, Italy and lead study author, commented that the article was meant to “give practical clinical advice to avoid preventable ischemic strokes relative to inappropriate use of hormonal contraception in women with migraine.”

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Sacco S, Merki-Feld GS, Ægidius KL, et al. Hormonal contraceptives and risk of ischemic stroke in women with migraine: a consensus statement from the European Headache Federation (EHF) and the European Society of Contraception and Reproductive Health (ESC). J Headache Pain. 2017;18(1):108.