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Evidence summaries

Risk of Ischaemic Stroke in Persons with Migraine Without Aura Using Combined Hormonal Contraception

Use of combined hormonal contraception may not be a risk factor for ischaemic stroke in women with migraine without aura and no additional risk factors compared with nonusers. Level of evidence: "C"

Summary

A case-control study 1 based on nationwide database assessed the risk of stroke associated with migraine and combined hormonal contraceptives. During years 2006 to 2012, there were 25 887 ischemic strokes among females ages 15-49 years. Compared to those with neither migraine nor combined hormonal contraceptive use, odds ratio (OR) for ischemic stroke among those with migraine with aura using combined hormonal contraception (CHC) was 6.1 (95% CI 3.1 to 12.1); migraine with aura without CHC 2.7 (95% CI 1.9 to 3.7). However, in women with migraine without aura the use of CHC did not increase the risk (migraine without aura with CHC RR 1.8, 95% CI 1.1 to 2.9, and migraine without aura without CHC RR 2.2, 95% CI 1.9 to 2.7).

In two earlier meta-analyses of case-control and cohort studies 2 3 assessing the risk of stroke in persons with migraine without aura, the risk of stroke was not increased.Use of contraception was not included.

A consensus statement 4 evaluated the absolute risk of ischemic stroke in women aged 20 to 44 years in relation to the use of hormonal contraception and migraine status. The definition of a clear association between migraine without aura and ischemic stroke was very complex as some studies did not include information on migraine aura and because of the challenge of aura diagnosis in epidemiological studies. The consensus statement writers (European Headache Federation and the European Society of Contraception and Reproductive Health) suggest for women with migraine without aura and without additional risk factors CHCs containing ≤ 35μg dose of ethinylestradiol as a possible contraceptive option. For women who develop new onset of migraine with or without aura in a temporal relationship to starting the hormonal contraceptive, switching to non-hormonal contraception or progestogen-only contraceptives is suggested. For women with migraine without aura and additional risk factors (like cigarette smoking, arterial hypertension, obesity, previous history of cardiovascular disease, previous history of deep vein thrombosis or pulmonary embolism) non-hormonal contraception or progestogen-only contraceptives are suggested as the preferential option.

Clinical comments

Note

Date of latest search: 2024-04-30

    References

    • Champaloux SW, Tepper NK, Monsour M, et al. Use of combined hormonal contraceptives among women with migraines and risk of ischemic stroke. Am J Obstet Gynecol 2017;216(5):489.e1-489.e7 [PubMed]
    • Schürks M, Rist PM, Bigal ME, et al. Migraine and cardiovascular disease: systematic review and meta-analysis. BMJ 2009;339():b3914 [PubMed]
    • Spector JT, Kahn SR, Jones MR, et al. Migraine headache and ischemic stroke risk: an updated meta-analysis. Am J Med 2010;123(7):612-24 [PubMed]
    • 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 [PubMed]

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