You probably aren’t surprised to hear that patients mention headaches to me quite often. Several months ago, after a long and in depth discussion of birth control options with a patient who suffers from migraine headaches, I promised her a blog entry about the topic.  She was taking normal birth control pills (that contains both estrogen and progesterone, which we refer to as combined oral contraceptives, and I’ll just call “the pill” for the next of this post).  She suffered from migraines with aura and I told her to immediately stop her birth control pill and that she was never allowed to take them again because her risk of stroke was too high. In her years of taking the pill and having migraines with aura no one had ever counseled her like this. She was surprised. And disappointed. She had to stop her beloved pills?  She needed more convincing. This is what I told her:
Let’s separate the information into a few question categories:

First, what’s the difference between migraine and other types of headaches?
You mean you’re not an avid follower of my blog? I just wrote about this! See this post. I made a nice chart for you.

You said increased risk of stroke. Is having migraine with aura dangerous in and of itself, or just if I take the pill?
Women who suffer from migraine with aura have an overall increased risk of stroke, cardiac disease, abnormal eye vasculature, and overall mortality, with or without the pill. If you have migraine with aura you need to be followed by a neurologist or an internist who knows their stuff.

So what about migraine with aura and the pill?
You have a 2-4X elevated risk of stroke compared to not taking the pill.

What puts you in even more danger? If you are older than 35, are obese, have diabetes, high blood pressure, high cholesterol, preexisting heart disease … the list goes on. Basically if you have other medical problems then you’re at increased risk.

I know you don’t need one more health benefit to NOT smoking but here it is: if you smoke AND have migraine with aura AND use the pill: your risk for stroke is 7X higher.

What if my last migraine with aura was years ago?
We’re not sure. Some studies say yes, you still have an increased risk of stroke. Some studies say no. This is definitely a risk / benefit ratio you need to discuss with your gynecologist and neurologist.

Is there danger with migraine headaches without aura and the pill?
With preexisting migraine headaches, up to 50% of women who start the pill may have worsening in frequency or severity. But … up to 35% of women may have improvement and up to 65% of women will have no change.

I know, I know, these numbers don’t add up to 100% (because the numbers are compiled from multiple studies, I didn’t give the range, I just gave the upper limit).

You may be most prone to migraine during the placebo week. Combined with your period, that week may be just miserable. If you skip the placebo week altogether and take the hormone pills continuously, you can skip your period and skip your migraine. Yay! (and yes, it’s safe to not have a period if you are intentionally doing it with pills).

Is there danger with regular (tension-type) headaches and the combined pill?
Short answer: no.

Headaches are a common complaint in the early months of use but they usually go away by themselves. And these types of headaches are just annoying, not harmful.

If I can’t take the pill, what can I use?
This is the burning question.
The best kind of contraception for you is something non- hormonal, like condoms, the copper IUD, withdrawal (obviously NOT ideal), natural family planning, or even sterilization if you’re ready for that. If you love your pill, these aren’t always great alternatives, I know.

This is another one of those risk / benefit discussions you need to have.

Sources:Migraine in Women. J Headache Pain. 2012; 13:177-189.
Contraception and Headaches. Headache. 2013; 53:247-276.