Oral Contraceptives for Menstrual Migraine with Aura

This clinical decision article explores the controversial use of combined oral contraceptives (COCs) in a 30-year-old woman with menstrual migraines accompanied by aura. The case vignette presents a patient seeking COCs for both contraception and migraine management. Two experts debate the options:

• Option 1 (Nappi) argues for COC use, citing potential benefits in stabilizing estrogen fluctuations to reduce menstrual migraines, especially with low dose or natural estrogen formulations, despite guidelines listing migraine with aura as a contraindication due to stroke risk.

• Option 2 (Cwiak) advises against COCs, emphasizing the elevated stroke risk in migraine with aura patients and advocating for safer alternatives like progestin nonly or nonhormonal contraceptives.

The discussion highlights the need for individualized risk benefit assessments, considering newer therapies (e.g., gepants) and patient priorities (contraception vs. migraine control).

This clinical decision article explores the controversial use of combined oral contraceptives (COCs) in a 30-year-old woman with menstrual migraines accompanied by aura. The case vignette presents a patient seeking COCs for both contraception and migraine management. Two experts debate the options:

• Option 1 (Nappi) argues for COC use, citing potential benefits in stabilizing estrogen fluctuations to reduce menstrual migraines, especially with low dose or natural estrogen formulations, despite guidelines listing migraine with aura as a contraindication due to stroke risk.

• Option 2 (Cwiak) advises against COCs, emphasizing the elevated stroke risk in migraine with aura patients and advocating for safer alternatives like progestin nonly or nonhormonal contraceptives.

The discussion highlights the need for individualized risk benefit assessments, considering newer therapies (e.g., gepants) and patient priorities (contraception vs. migraine control).