People who get migraines with aura—dots or zigzags in vision, or another sensory disturbance that typically occurs before the onset of a migraine—have long been told to avoid birth control that contains estrogen. The hormone has been linked to an increased risk of stroke in this population.
How great is the risk, and what should you do if you’re one of the 25% of women of reproductive age who get migraines? Here’s what doctors say.
The connection between migraines and stroke risk
For years, doctors and medical associations have warned that people who get migraines with aura may have an increased risk of stroke if they take supplemental estrogen. Many forms of birth control contain estrogen—including some types of birth control pills, the birth control patch, and the vaginal birth control ring. They’re known as combined hormonal contraceptives because they contain two hormones: estrogen and progestin.
Combined hormonal contraceptives “are safe for most people,” according to the American College of Obstetricians and Gynecologists. But they are associated with a small risk of stroke, and that risk is higher in people with certain risk factors, such as those who get migraines with aura. People who get migraines with aura already have a higher baseline risk of stroke because they may be more likely to form blood clots, according to the American Migraine Foundation, and estrogen supplements can increase the formation of small blood clots.
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“Estrogen-containing birth control can increase your risk of having a stroke independently, and having migraines with aura also increases your risk of having a stroke independent of other risk factors, so combining those two risk factors together has just been deemed too risky for that increased risk of stroke,” says Dr. Franziska Haydanek, an ob-gyn based in Rochester, New York.
Determining your individual risk
Some experts, though, say the risk for this population may not be as high as it used to be. Dr. Jelena Pavlovic, a neurologist and headache specialist based in the Bronx, says that the recommendation that people who experience migraines with aura avoid estrogen-containing contraceptives was established years ago, when the birth-control methods on the market contained higher doses of estrogen. The contraceptives available today contain much lower doses of estrogen, she says, and “we do not have updated, large-scale data” to evaluate the risk of these new formulations of contraceptives for people who have migraines with aura. Past research has indicated that, in general, people who have taken contraceptives with lower doses of estrogen have a decreased risk of stroke compared to those who use methods with more estrogen. Other medical experts have also shared similar thoughts on the current recommendations.
But that doesn’t necessarily mean people who get migraines with aura should use estrogen-containing contraceptives.
“As [with] everything in medicine, the first rule is ‘do no harm,’” Pavlovic says. “So we tend to err on the side of caution.”
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She says that the use of estrogen-containing contraceptives should “be considered on a case-by-case basis,” depending on the consistency, severity, and type of migraine a person has. People should consult with both their gynecologist and neurologist to discuss birth-control options. If a person’s migraines don’t evolve and are relatively well-controlled, and if they don’t have other risk factors, such as smoking, they and their doctors may consider introducing lower doses of an estrogen-containing contraceptive and monitoring how it goes.
While high doses of estrogen can carry an increased risk of stroke, the hormone can, at lower doses, also be used to treat and stabilize migraines.
“If a woman with migraine with aura is denied access to combined hormonal contraceptives because of very stringent guidelines, not only is she losing a contraceptive option, she’s also potentially losing a migraine treatment option,” Pavlovic says.
Other birth-control options
If a patient consults with their doctors and they determine that their level of risk is too high to use an estrogen-containing contraceptive, there are many other birth-control methods that don’t contain estrogen that they can turn to instead, including progestin-only birth control pills, the birth control injection, and IUDs, according to Haydanek.
In recent years, ob-gyns have expressed concerns about a wave of people quitting birth control and instead relying on “natural” methods that are less effective. Misinformation about birth control regularly circulates on social-media platforms, like TikTok.
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While social media can help share important health information, people shouldn’t rely solely on it, Haydanek says. Instead, she recommends that they consult with their doctors if they have any questions or concerns.
“Overall, birth control is a very safe medication, but every person’s own medical history obviously plays into that,” Haydanek says. “If [people] ever have concerns about how birth control is affecting them or their risk, they really should schedule a problem visit with their ob-gyn to really discuss those concerns.”
