Combined oral contraceptives migraine and ischaemic stroke. Recommendations for clinical practice.

The low incidence of ischemic stroke in reproductive-age women is higher among women who suffer from migraine especially if the women also take combined oral contraceptives (COCs). Although the overall risk of stroke is small available data suggest that certain groups of women with migraine using COCs are at greater risk than others. Migraine with aura in which there are focal neurological symptoms preceding the onset of headache and unusually severe migraine attacks lasting longer than 72 hours despite treatment either with pre-existing migraine or one which develops during COC use are absolute contraindications to COC use. Other absolute contraindications are migraine aura in a woman with a history of more than one additional risk factor for stroke and cases in which migraine is treated with ergot derivatives. In the case of migraine without aura in a woman with an history of one additional risk factor for stroke which is not an absolute contraindication to COC the disadvantages of COC use typically outweigh the advantages but COCs can nonetheless be used with caution. In the following situations the advantages of COC use by women with migraine generally outweigh the disadvantages: migraine without aura in women with no additional risk factors for stroke and in whom there is no marked increased in migraine frequency associated with COC use as well as in the treatment of acute migraine with naratriptan sumatriptan or zolmitriptan.