Oral contraceptives containing estrogen, even those of the low-dose variety, are associated with a small but notable increased risk of stroke. Because migraine with aura is also linked to a small but notable further increased risk of stroke, the danger is compounded if a woman with the condition chooses to go on these birth control pills. This risk is yet further increased for those who smoke.

Migraine without aura is not associated with an increased stroke risk, so estrogen-based oral contraceptives may be a viable treatment choice for you if you have never experienced aura, if you are under age thirty-five, and if you have no other cardiovascular risk factors (especially smoking). A low-dose oral contraceptive may be preferred to try and avoid large fluctuations in estrogen levels during the menstrual cycle.

Certain types of oral contraceptives that involve a week of “placebo” treatment (i.e., the inactive pills taken during the last week of the twenty-eight-day cycle) are associated with an increased incidence of migraine attacks during the placebo period. Keep a diary when you first start your course of contraceptives to see how the placebo period affects your migraine patterns.

It's possible to supplement your “placebo period” with another form of migraine treatment to prevent unwanted attacks. Your doctor can advise you on the options that exist and how they fit your health history and lifestyle needs.

If you choose to go on estrogen oral contraception because your migraines don't involve aura and you have no other cardiovascular risk factors, be vigilant. If at any point during treatment you begin to experience aura or other visual disturbances let your doctor know immediately as you may need to consider discontinuing their use.

For migraineurs who can't tolerate estrogen-based oral contraception, progestin-only pills (POP, or minipill) may be a viable choice. The minipill works by thickening the cervical mucus (to inhibit the transport of sperm) and suppressing ovulation. However, its efficacy rate in preventing pregnancy is lower than an estrogen-containing contraceptive.

The minipill is good news for women who have migraine with aura who prefer oral contraceptives over other options. Studies to date indicate that progestin-only pills are not associated with the increased risk of stroke that estrogen-based pills are, so migraine with aura patients can safely use them, as can women over the age of thirty-five.