Journals club: Migraine, stroke and combined oral contraception use

Contributed by Dr Louise Newson, a GP in the West Midlands.

A brain CT scan demonstrating stroke
A brain CT scan demonstrating stroke

Curriculum statement 10.1 Women's health and 15.7 neurological problems

Key trials

  • A meta-analysis showed that the risk of ischaemic stroke in migraine sufferers who experience aura is twice that found in people without migraine (BMJ 2009; 339: b3914).
  • The risk of stroke increases further in women with migraine with aura who also take the combined oral contraceptive pill (COCP).
  • The absolute risk of stroke in women with migraine is still low: 17-19 per 100,000 women-years (J Fam Plann Reprod Health Care 2003;29:209-22).
  • One review found evidence that migraine with aura is not only a risk factor for ischaemic stroke but also for MI and other ischemic vascular events (Curr Opin Neurol 2007; 20: 310-9).
  • Migraine seems to affect neurovascular factors and substances that increase the risk of stroke during and in between migraine attacks. Migraine patients are more likely to have a patent foramen ovale, a well-known risk factor for stroke (Intern Emerg Med 2008; 3 Suppl 1:S9-16).

Evidence base

  • Women who have migraine with aura should not take the COCP because the risk of stroke is unacceptably high (Headache 2005; 45: 224-31).
  • Prescribing formularies states that the COCP should be avoided in women who have: migraine with aura; severe migraine lasting more than 72 hours despite treatment; or migraine treated with ergot derivatives.
  • However, a recent BMJ editorial has stated that a blanket ban on prescribing the COCP to women with migraines with aura is hard to justify (BMJ 2009; 339: b4380).
  • It has been recommended that clinicians have a heightened vigilance for modifiable cardiovascular risk factors in patients with migraines, especially those who experience aura. (Neurology 2009; 72: 1864-71).

Guidelines


Useful websites

 

Key Points
  • Migraine with aura is associated with a higher risk of stroke and cardiovascular disease.
  • A patent foramen ovale is more common in migraine patients.
  • The combined oral contraceptive pill is contraindicated in patients who have migraines with aura.

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