COC use and migraines. (Clinical Challenges).

A 28-year-old mother of two who often suffers from headaches has traveled two hours to reach the family planning clinic. She wants a contraceptive method that will help her delay the birth of another child and is considering combined oral contraceptives (COCs). She has steady work that involves a regular schedule and feels that she could consistently take pills each morning before work. She has heard from her friends that COCs will not cause any irregular bleeding that might interfere with her work. Would COC use be advisable in her case?

Unless she has risk factors for stroke, a woman experiencing headaches that are not migraines can safely initiate COC use. However, distinguishing severe headaches from migraines and evaluating any new headaches with aura (visual, auditory, olfactory, or other symptoms before pain onset) or marked changes in headaches is important. Thus, before COCs are prescribed, likely causes of the woman's headache should be explored and a diagnosis made. In the meantime, nonhormonal contraceptives such as condoms should be offered to her.

Women with a history of both migraine and COC use are two to four times more likely to have a stroke than women with a history of migraine alone, according to case-control studies that have examined COC use, history of migraine, and risk of stroke. (1) The World Health Organization's medical eligibility criteria state that women with migraines can safely use COCs as long as they do not have focal neurologic symptoms and are younger than 35 years. (2) But COC initiation by women who are 35 years or older and have migraines (even those without focal neurologic symptoms) is not recommended. No woman experiencing migraines with focal neurologic symptoms (such as an aura) should use COCs.

(1.) Curtis KM, Chrisman CE, Peterson HB. Contraception for women in selected circumstances. Obstet Gynecol 2002;99(6):1100-12; Lidegaard O. Oral contraceptives, pregnancy and the risk of cerebral thromboembolism: the influence of diabetes, hypertension, migraine and previous thrombotic disease. BrJ Obstet Gynaecol 1995;102(2): 153-59; Chang CL, Donaghy M, Poulter N, et al. Migraine and stroke in young women: case-control study. BM] 1999;318(7175):13-18; Tzourio C, Tehindrazanarivelo A, Iglesias S, et al. Case-control study of migraine and risk of ischemic stroke in young women. BM] 1995;310(6983):830-33; Schwartz SM, Petitti DB, Siscovick DS, et al. Stroke and use of low-dose oral contraceptives in young women: a pooled analysis of two U.S. studies. Stroke 1998;29(11):2277-84.

(2.) World Health Organization. Improving Access to Quality Care in Family Planning. Medical Eligibility Criteria for Contraceptive Use. Geneva, Switzerland: World Health Organization, 2000.