Combined hormonal contraception in migraine with aura
A 27-year-old woman has had migraine with aura since age 16, with three to four attacks per month. She takes propranolol 80 mg modified release daily. She smokes 10 cigarettes a day and requests the combined oral contraceptive for heavy, painful periods and acne. Blood pressure is 116/72 mmHg, BMI 23 kg/m². She has no personal or family history of venous thromboembolism, and no other cardiovascular risk factors; her mother had a stroke at 70. She tried the progestogen-only pill (desogestrel) but stopped because of unscheduled bleeding. She is not currently sexually active but plans to be, and she is adamant she does not want an intrauterine device. She asks whether the pill is safe.
1. Is the combined oral contraceptive appropriate? Explain the risk and the relevant guidance.
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No. Migraine with aura is a WHO Medical Eligibility Criteria category 4 condition for combined hormonal contraception-an absolute contraindication-because it roughly doubles or more the already raised ischaemic stroke risk associated with aura. Her smoking under age 35 would be category 3 on its own, but aura alone makes it category 4. Combined patches and vaginal rings contain oestrogen and carry the same restriction.
Quantify the risk honestly: baseline stroke risk in a young woman is very low (a few per 100,000 per year), but the combination of aura and oestrogen raises it several-fold, and the consequence can be devastating. Her heavy periods and acne are important, but they do not justify a method that increases stroke risk. Explain that the progestogen-only pill's unscheduled bleeding is common in the first months and is not dangerous; it can often be managed by continuing it or switching progestogen. Document the counselling and that she was advised against combined hormonal contraception.
2. What contraceptive alternatives would you offer, and how would you manage her migraines and smoking?
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Offer progestogen-only methods. Desogestrel 75 micrograms daily can be taken continuously and often reduces menstrual bleeding; explain that unscheduled bleeding usually settles and can be managed without stopping. The etonogestrel implant is highly effective for three years and frequently reduces dysmenorrhoea and bleeding. Although she does not want an intrauterine device, mention that the levonorgestrel intrauterine system is the most effective treatment for heavy periods, in case she changes her mind. Depot medroxyprogesterone acetate is an option but may cause irregular bleeding and affects bone density with prolonged use. Condoms should be used for STI protection.
For migraine, check that propranolol 80 mg is being taken consistently and consider increasing if attacks remain frequent. Discuss triggers, sleep and hydration. Topiramate is teratogenic and should not be started without robust pregnancy prevention. Address smoking as a vascular risk and offer cessation support. For acne, consider topical retinoid or benzoyl peroxide, and avoid oestrogen-containing treatments. If she needs emergency contraception, levonorgestrel or ulipristal are suitable; a copper coil is the most effective option.
3. What follow-up and safety advice would you give, and what would you do if she stopped smoking?
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Review in three months to assess bleeding pattern, blood pressure, migraine frequency and satisfaction. Give safety advice about aura symptoms, weakness, speech disturbance or sudden severe headache, which require urgent assessment. Document that combined hormonal contraception remains contraindicated even if she stops smoking, because the aura is the decisive factor. If her migraine pattern changes-for example, aura occurring for the first time over age 50, prolonged aura, or new focal symptoms-reassess and consider referral. Discuss what she would do if she became pregnant and ensure her cervical screening is up to date when due. Provide written information and a clear plan for unscheduled bleeding.