Reducing Stroke Risk in Women With Migraine Receiving Hormonal Contraceptives: Consensus Statement

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Women with migraine face an increased risk of stroke if they are prescribed hormonal contraceptives.
Women with migraine face an increased risk of stroke if they are prescribed hormonal contraceptives.

A new consensus statement from the European Headache Federation published in the Journal of Headache and Pain provides new information on the association between hormonal contraceptive (HC) use and ischemic stroke risk in women with migraine and offers 13 statements that can guide clinical practice for these women.

A panel comprised of multidisciplinary experts in cardiovascular disease, HC, and migraine performed a systematic literature review of observational and randomized controlled trials to determine the association between migraine and cardiovascular risk among women taking HCs.

The association between HC use and stroke risk in women with migraine was evaluated in 6 studies, all of which were included in the final analysis. 

In one of the studies, researchers demonstrated that the ischemic stroke risk increased 2-fold among women with migraine who took HCs compared with women with migraine who did not use HCs (odds ratio [OR] 2.1; 95% CI, 1.2-3.7).

A similar study found that female HC users with migraine had a 14-fold increased risk for stroke (OR 13.9; 95% CI, 5.5-35.1) compared with a 4-fold risk among non-HC users (OR 3.7; 95% CI, 1.5-9.1). Additionally, another study found a 7-fold greater risk for ischemic stroke in women who smoked and used HCs vs women who did not smoke and did not use HCs (OR 7.0; 95% CI, 1.4-22.8).

In a consensus statement, the panel suggests women should undergo clinical examination for migraine prior to using HCs. Additionally, these women should be screened for cardiovascular risk factors, such as tobacco use, obesity, hypertension, and cardiovascular disease history, prior to use. In addition, the panel recommends careful selection of contraceptive types, with particular avoidance of high-risk products such as combined oral HCs consisting of >35 μg ethinylestradiol.

Although this statement provides potentially helpful guidelines for women with migraine who use or are considering taking HCs, it fails to identify safe methods for contraceptive use. In addition, the statement does not make clear the underlying mechanisms between HC use and stroke risk in women with migraine.

Whereas the researchers indicate that, “even if the absolute risk associated with the use of combined HCs may not be high,” the effects of an ischemic stroke outweigh the potential risk.

Reference

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.

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