Migraine with Aura and Estrogen Birth Control: What You Need to Know About Stroke Risk

If you get migraines with aura and are thinking about birth control, you’re not alone. But you’re also facing a decision that could affect your long-term health. The question isn’t just migraine with aura and birth control-it’s whether the combination might raise your risk of stroke. And the answer isn’t simple.

What Exactly Is Migraine with Aura?

Migraine with aura isn’t just a bad headache. It’s a neurological event. Before the pain hits, you might see flashing lights, blind spots, or zigzag lines. Some people feel tingling in their hands or face. Others have trouble speaking. These symptoms last 5 to 60 minutes and are followed by a pounding headache, nausea, or extreme sensitivity to light.

Crucially, aura means focal neurological symptoms. That’s the key. Nausea, fatigue, or mood changes before a migraine? Those are warning signs, not aura. Only visual, sensory, or speech disturbances count. If you’ve had these symptoms even once, you’re in a higher-risk group when it comes to estrogen-based birth control.

Why Estrogen Is the Problem

Estrogen in birth control pills, patches, or rings increases blood clotting. That’s how it prevents pregnancy-it stops ovulation and thickens cervical mucus. But in some women, that same effect can lead to clots in the brain, causing ischemic stroke.

The numbers are startling. Healthy young women without migraines have about a 6 in 100,000 chance of having an ischemic stroke each year. For women with migraine with aura who take estrogen-containing birth control, that jumps to about 30 in 100,000. That’s a fivefold increase. The CDC says the combined risk-migraine with aura plus estrogen-is six times higher than having neither.

It’s not just about the pill. Any estrogen-containing method-patch, ring, or combination pill-carries this risk. The World Health Organization (WHO) has said since 2015: Do not use estrogen-containing contraceptives if you have migraine with aura. That’s a Category 4 recommendation-the highest level of risk. It’s not a suggestion. It’s a hard stop.

But New Research Says It Might Be Safer

Here’s where things get messy. A 2022 study by Dr. Pinar Batur at the American Migraine Foundation looked at women with migraine with aura using modern low-dose birth control. The results? Stroke risk didn’t spike as much as older studies suggested-especially with pills containing less than 30 micrograms of ethinyl estradiol.

Modern birth control pills now come in ultra-low doses: 10 to 15 micrograms of estrogen. That’s a fraction of what was used in the 1970s, when early studies first linked estrogen to stroke. Dr. Anne Calhoun, writing in Headache in 2017, argues that today’s pills may not raise stroke risk at all-and might even reduce aura frequency by stabilizing hormone swings.

But here’s the catch: Batur’s study included only 127 women who had strokes. That’s too small to draw firm conclusions. And while her findings are promising, they haven’t changed official guidelines. The WHO, CDC, and American College of Obstetricians and Gynecologists (ACOG) still say: avoid estrogen if you have aura.

Frequency Matters More Than You Think

Not all migraines are equal. How often you get them changes the risk.

Studies show women who have migraine with aura more than 12 times a year face a much higher stroke risk-up to 10 times higher-than those with fewer attacks. Even monthly attacks carry a 1.9 times higher risk. But here’s the surprising part: women who get migraines less than once a month also showed increased risk. The pattern isn’t linear. It’s J-shaped: both very frequent and very infrequent attacks carry danger.

And if you’ve had an aura attack in the past year? You’re still at elevated risk. But if your last aura was two years ago? The risk drops back toward baseline. That’s why doctors ask: When was your last aura? It’s not just history-it’s a current risk factor.

Other Risk Factors Make It Worse

Estrogen plus migraine with aura is dangerous. But add smoking, high blood pressure, diabetes, or a family history of stroke-and the risk skyrockets.

If you’re over 35 and smoke? Estrogen birth control is absolutely off-limits, even without migraines. Add migraine with aura? That’s a red flag you can’t ignore.

That’s why doctors don’t just look at your headache history. They check your blood pressure. They ask if you smoke. They want to know about your parents’ health. One risk factor alone might be manageable. Two or three? That’s when the danger becomes real.

What Are Your Safe Alternatives?

You don’t have to go without birth control. There are plenty of options that don’t raise your stroke risk.

• Progestin-only pill (POP): Also called the mini-pill. Takes daily. No estrogen. Safe for migraine with aura.
• Implant (etonogestrel): A small rod placed under the skin of your arm. Works for up to 3 years. Over 99% effective.
• Levonorgestrel IUD: A T-shaped device inserted in the uterus. Lasts 3 to 8 years. Reduces or stops periods. No estrogen.
• Depo-Provera shot: Given every 3 months. Progestin only.
• Copper IUD: Hormone-free. Works for up to 12 years. Just as effective as hormonal IUDs.
• Barrier methods: Condoms, diaphragms, cervical caps. Lower effectiveness but zero hormonal risk.

These methods don’t increase stroke risk. They don’t interfere with your migraines. And many-like the IUD or implant-are long-lasting and forgettable. You don’t have to remember a pill every day.

What If You’re Already on Estrogen Birth Control?

If you’ve been on the pill and just found out you have migraine with aura, don’t panic. But don’t ignore it either.

Stop the estrogen-based method. Talk to your provider. Switch to a progestin-only option. Most women transition smoothly. Some report fewer migraines once they’re off estrogen. Others notice no change.

Keep track of your symptoms. If you start getting new or worse auras after switching, tell your doctor. It might be a coincidence. Or it might mean you need a different method.

The Bottom Line

There’s no perfect answer. The science isn’t settled. But the safest path is clear: if you have migraine with aura, avoid estrogen-containing birth control. The risk of stroke, while still rare overall, is real and avoidable.

Progestin-only methods are effective, safe, and widely available. They don’t carry the same risks. And for many women, they work better than they expected.

Don’t let fear stop you from using birth control. But don’t let outdated assumptions or conflicting studies lead you into danger. Get your migraine type confirmed. Know your attack frequency. Check your blood pressure. Talk to your doctor. And choose a method that protects your brain as much as your fertility.

When to See a Specialist

See a neurologist or headache specialist if:

• Your aura lasts longer than an hour
• You have aura without a headache
• You have weakness or numbness on one side of your body
• You’ve had more than 12 aura attacks in a year
• You’re over 35 and smoke

These aren’t normal migraines. They need expert evaluation. And your birth control plan should be part of that plan.