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)

Abstract

Several data indicate that migraine, especially migraine with aura, is associated with an increased risk of ischemic stroke and other vascular events. Of concern is whether the risk of ischemic stroke in migraineurs is magnified by the use of hormonal contraceptives. As migraine prevalence is high in women of reproductive age, it is common to face the issue of migraine and hormonal contraceptive use in clinical practice. In this document, we systematically reviewed data about the association between migraine, ischemic stroke and hormonal contraceptive use. Thereafter a consensus procedure among international experts was done to develop statements to support clinical decision making, in terms of cardiovascular safety, for prescription of hormonal contraceptives to women with migraine. Overall, quality of current evidence regarding the risk of ischemic stroke in migraineurs associated with the use of hormonal contraceptives is low. Available data suggest that combined hormonal contraceptive may further increase the risk of ischemic stroke in those who have migraine, specifically migraine with aura. Thus, our current statements privilege safety and provide several suggestions to try to avoid possible risks. As the quality of available data is poor further research is needed on this topic to increase safe use of hormonal contraceptives in women with migraine.

Migraine and Ischemic Stroke in Women. A Narrative Review

“…Use of CHC by women with MWA was associated with a 6‐fold increased risk of ischemic stroke compared to women with neither risk factor, whereas compared to the control group, CHC use did not substantially alter risk of ischemic stroke for women with MWoA. This study was included in a systematic review of CHC use, migraine, and ischemic stroke conducted by the European Headache Federation (EHF) and the European Society of Contraception and Reproductive Health 59 . The authors calculated the absolute risk of ischemic stroke for women not using CHC to be 2.5 strokes per 100,000 women‐years in women without migraine, 5.9 strokes per 100,000 women‐years in women with MWA, and 4.0/100,000 women‐years in those with MWoA.…”

“… Women with active MWA should stop smoking and adopt a lifestyle that fosters vascular health (ie, regular exercise, stress management, and if needed, weight loss). If labs suggest endothelial activation or dysfunction, consider migraine prophylaxis with lisinopril 130 or candesartan, 131 and/or a statin plus vitamin D3, 190 particularly if there is dyslipidemia. Women with active MWA should not be started on CHC 59,191,192 Women with active MWA on CHC, especially those who develop MWA after starting CHC, should switch to a nonhormonal contraceptive or progestogen‐only contraceptive. 59,191‐194 A trial of an antiplatelet agent should be considered in women with active MWA, especially if continuing on CHC, or if there is evidence of endothelial dysfunction, hypercoagulability, PFO, or stroke‐like lesions on brain MRI. Although some experts support PFO screening and closure in high‐risk populations, given negative RCTs to date, percutaneous closure is not recommended for migraine outside a clinical trial. A new PFO‐migraine trial registered with clinicaltrials.gov is designed to determine whether there are migraine subgroups who might benefit from percutaneous PFO closure 186 …”

Effect of exogenous estrogens and progestogens on the course of migraine during reproductive age: a consensus statement by the European Headache Federation (EHF) and the European Society of Contraception and Reproductive Health (ESCRH)

“…From a cardiovascular point of view in women with migraine it is also the safest form [22, 46]. The desogestrel pill may improve migraine frequency and severity in women with MA or MO not necessarily related to menstruation.…”

Migraine: navigating the hormonal minefield

“…Progestogen-only contraceptives do not increase the risk of stroke. Consequently, the current guidance is to avoid the combined oral contraceptive pill in women with migraine with aura 30…”