If your migraines come with a warning, flashing lights, zigzag lines across your vision, numbness creeping up one hand, or the strange feeling that words won’t form properly, you are not just experiencing a more dramatic type of headache. You are experiencing migraine with aura, and it carries cardiovascular implications that too many people are never told about, especially when they walk into a clinic or pharmacy asking about contraception.
This is not a reason to panic. But it is absolutely a reason to pay attention.
What Is Migraine with Aura, really?
Migraine with aura is a subtype of migraine that affects roughly one in four people who live with the condition. The “aura” refers to temporary neurological symptoms that typically begin 20 to 60 minutes before the headache hits, visual disturbances are the most common, but aura can also involve tingling sensations, weakness, or speech difficulties.
What makes aura medically significant beyond the symptoms themselves is what is happening inside the brain when it occurs. According to research into the shared pathophysiology of migraine and stroke, the connection between the two conditions runs through a phenomenon called cortical spreading depression, a slow, self-propagating wave of electrical activity that moves across the brain’s surface, temporarily disrupting normal function.
This is the mechanism that produces the aura you see or feel. At the same time, these changes can affect blood flow in the brain. Studies show that these changes in vascular perfusion may be associated with vasospasm, which can lead to reduced blood flow in the brain and, in some cases, ischemic stroke.
In other words, the aura is not just a warning sign for pain. It is a window into a brain that, under certain conditions, is working in a way that raises its vulnerability to stroke. Research has also identified endothelial dysfunction and, in some individuals, genetic predispositions as part of this shared biological picture between migraine and stroke.
The Stroke Connection You May Not Know About
According to data from the American Migraine Foundation, women with aura are two to three times more likely to have a stroke than women without migraine, and women with aura face a higher stroke risk than men with aura in the same age group.
That statistic deserves a moment to sit with. It is not a reason to live in fear, the absolute risk remains small in otherwise healthy, young, non-smoking women, but it is a clinical reality that must factor into every healthcare decision you make, particularly around hormonal contraception.
Studies show that women below the age of 45 who have migraine with aura face a notably higher risk of ischemic stroke the type caused by a clot blocking blood flow to the brain. Research has pointed to several mechanisms behind this. According to a published meta-analysis on migraine and ischemic stroke, migraine may increase stroke risk through vasospasm induced reductions in cerebral blood flow, increased platelet aggregation, and elevated concentrations of pro coagulant factors including von Willebrand factor and antiphospholipid antibodies.
There is also the question of aura frequency. According to research published in a major review of migraine pathophysiology, the risk of ischemic stroke in people with less than one aura attack per month is twofold, and this rises to fourfold in those experiencing more than one attack per week. In simple terms, more frequent aura means more repeated exposure to these vascular changes, and a higher overall risk profile.
Where Contraception Enters the Picture
Here is where things get clinically important, and where a lot of women are, unfortunately, either not told or not told clearly enough.
According to clinical guidance from multiple headache and contraception bodies, both migraine with aura and combined hormonal contraceptives are independently linked to a small increased risk of stroke, and when the two are combined, that risk compounds in a way that is considered clinically significant. Combined hormonal contraceptives, which include the combined oral contraceptive pill, the contraceptive patch, and the vaginal ring, all contain oestrogen, and it is that oestrogen component that drives the additional vascular concern.
Why does this matter? Because oestrogen can influence clotting pathways and blood vessel behavior, amplifying an already vulnerable system in people with aura.
Studies show that current guidelines restrict the use of combined hormonal contraceptives specifically in the setting of migraine with aura, but not in migraine without aura. The consensus across major medical bodies is that the risk associated with combined hormonal contraception in this population typically outweighs its benefits, framed in some guidelines as posing an unacceptable health risk when safer alternatives are available.
The concern is not just theoretical. A large cohort study spanning more than 470,000 person-years with a median follow up of 26 years confirmed that migraine with aura specifically, not migraine without aura, carries a twofold increased risk of ischemic stroke. Adding combined hormonal contraceptives to this baseline risk further increases the likelihood of a vascular event, even if the absolute risk remains low.
According to a five-year case-control study conducted in Denmark, the risk of stroke with combined oral contraceptives correlated directly with the oestrogen content of the formulation.
Reassuringly, lower-dose formulations showed substantially reduced arterial risk compared to older high dose pills, but the guidance remains clear: for women with migraine with aura, the combined pill should be avoided regardless of dose.
The Reality Gap (Who Is Still Being Prescribed It?
Despite clear clinical guidelines, the gap between guidance and real-world prescribing is wider than it should be. (A 2025 study published in Pharmacoepidemiology and Drug Safety, conducted by researchers at Boston University, examined nearly 143,000 reproductive aged people diagnosed with migraine with aura over a 24-year period. The findings showed that a notable proportion of people with migraine with aura were still receiving prescriptions for combined oral contraceptives, despite treatment cautions and in many cases outright contraindications.
According to the study authors, many of those who continued receiving these prescriptions had already been using combined contraceptives before their migraine with aura diagnosis, suggesting that some of this reflects clinical inertia, a prescription continuing unchanged rather than being actively reviewed post diagnosis.
In practical terms, this means many women may continue using a contraceptive that guidelines advise against, simply because the prescription was never revisited. The researchers concluded that this pattern underscores the urgent need for both modern evidence and better communication between prescribers and patients at the point of diagnosis.
As a pharmacist, I find this gap clinically concerning. A migraine diagnosis, particularly one involving aura, should trigger an automatic medication review, and contraception must be part of that conversation.
What Are the Safer Options?
The good news is that women with migraine with aura are not left without effective contraceptive choices. Far from it.
According to current clinical guidance, progestogen only contraceptives, including the mini-pill, the contraceptive implant, the injection, and the hormonal intrauterine system, are all considered safe for women with migraine with aura. Non hormonal contraception is equally suitable. The key distinction is oestrogen: it is the oestrogen in combined contraceptives that interacts with the vascular vulnerability created by aura, and progestogen only methods do not carry this same concern.
According to research published in the Journal of Headache and Pain, progestogen only contraception does not appear to be associated with an increased risk of either venous thromboembolism or ischemic stroke, making it a clinically sound choice for this population.
Studies also suggest that certain progestogen only formulations, particularly those containing desogestrel 75 micrograms. may have a beneficial effect on migraine frequency itself, with evidence from headache diary studies showing reductions in attack days, lower analgesic use, and improvement in associated symptoms in some women.
Beyond hormonal options, the copper intrauterine device offers highly effective contraception with no hormonal component and no vascular risk, a straightforward choice for women who want to eliminate hormonal exposure entirely.
What This Means for You
If you have been diagnosed with migraine with aura, or if you experience visual disturbances, tingling, or temporary neurological symptoms with your headaches and have never been formally assessed, this conversation with your doctor, neurologist, or pharmacist genuinely matters.
Before any contraceptive is prescribed or continued, your aura status should be part of the discussion. If you are already on the combined pill and you have migraine with aura, do not stop it abruptly without speaking to a healthcare provider first, but do have that conversation as soon as possible.
According to the evidence, the stroke risk associated with migraine with aura, while small in absolute terms, is real and measurable. When that risk is compounded by combined hormonal contraception, studies show it becomes a risk that is unnecessary to take, especially when equally effective, safer alternatives are available.
Understanding your migraine subtype is not just about managing your pain. According to the research, it is about protecting your long-term cardiovascular health too.
FAQs
Q1. What is the difference between migraine with aura and migraine without aura?
Migraine without aura is a headache condition involving moderate to severe pain, nausea, and sensitivity to light and sound. Migraine with aura includes all of that but is preceded by temporary neurological symptoms, most commonly visual disturbances like zigzag lines or flashing lights, but also tingling, numbness, or brief speech difficulties. The distinction matters clinically because migraine with aura, not migraine without aura, is the subtype associated with an increased risk of ischemic stroke.
Q2. Can I take the combined pill if I only get aura occasionally?
According to current medical guidelines, migraine with aura is considered a contraindication to combined hormonal contraceptives regardless of how frequently the aura occurs. Even infrequent aura episodes indicate that the underlying vascular mechanism is present. The frequency of aura does influence the degree of stroke risk, studies show the risk rises with more frequent attacks, but the guidance to avoid the combined pill applies across the board. Speak with your doctor or pharmacist about switching to a progestogen only or non-hormonal method.
Q3. Is the progestogen only pill as effective as the combined pill?
Yes, according to clinical evidence, progestogen-only pills. particularly those containing desogestrel, are highly effective at preventing pregnancy when taken correctly, comparable in efficacy to the combined pill. Some progestogen-only methods, such as the implant and hormonal intrauterine system, are actually among the most effective forms of contraception available, with failure rates below 1%.
Q4. Could my combined pill have been causing my migraines to get worse?
Possibly. Oestrogen levels fluctuate across the combined pill cycle, and the hormone-free interval in particular can trigger what is known as oestrogen withdrawal migraine. Studies show that hormonal fluctuations are a recognised migraine trigger in women who are susceptible, and some women find their attacks become more frequent or more severe on the combined pill. If you have noticed a pattern between your pill cycle and your migraine attacks, that is worth discussing with your healthcare provider.
Q5. What should I do if I was already on the combined pill when I was diagnosed with migraine with aura?
Do not stop the combined pill abruptly without medical advice, an abrupt stop can itself trigger a hormonal migraine. Contact your doctor or pharmacist as soon as possible to discuss transitioning to a safer alternative. A progestogen only method can usually be started with minimal interruption to your contraceptive cover, and your provider can guide you through the switch safely.
Q6. Is non-hormonal contraception a realistic long-term option?
Absolutely. The copper intrauterine device is one of the most effective forms of contraception available, over 99% effective, and contains no hormones at all. It carries no vascular risk and can remain in place for several years depending on the type. For women with migraine with aura who want to avoid hormonal contraception entirely, it is a highly practical and clinically endorsed option.
Call to Action
If this article has made you think twice about your contraception, that is exactly the point. Migraine with aura is not just a headache pattern, it is a clinical detail that should be part of every contraceptive conversation you have with a healthcare provider. If you are unsure whether your current method is right for you, speak with your doctor, gynaecologist, or pharmacist and ask directly about your aura status and stroke risk.
For more evidence-based health content written in plain language, visit pharmahealths.com, where I break down the clinical details that matter for your everyday health decisions.
Disclaimer
This article is for informational purposes only and does not constitute medical advice. Always speak with a qualified healthcare provider about the contraceptive options most appropriate for your individual health history.
References
• American Migraine Foundation. Migraine, stroke and heart disease. americanmigrainefoundation.org
• American Migraine Foundation. Migraine and stroke. americanmigrainefoundation.org
• American Headache Society. Migraine with aura, contraceptives and stroke risk. americanheadachesociety.org
• Boston University School of Public Health. Combined oral contraceptive use among people with migraine with aura persists despite cautions. bu.edu/sph, December 2025
• Gibbs L et al. Utilization of oral contraceptives and hormone therapy for menopause among female individuals with migraine with aura: a descriptive study. Pharmacoepidemiology and Drug Safety. 2025. doi:10.1002/pds.70266
• Tepper NK et al. Safety of hormonal contraceptives among women with migraine. Contraception. Published in PMC April 2024. stacks.cdc.gov
• Sacco S et al. Hormonal contraceptives and risk of ischemic stroke in women with migraine: a consensus statement from the European Headache Federation and the European Society of Contraception and Reproductive Health. Journal of Headache and Pain. 2017;18(1):108
• Morotti M et al. Hormonal contraception in women with migraine: is progestogen-only contraception a better choice? Journal of Headache and Pain. 2014. PMC3735427
• Calhoun AH. Combined hormonal contraceptives and migraine: an update on the evidence. Cleveland Clinic Journal of Medicine. 2017;84(8):631
• Campos-Outcalt D. Migraine with aura and stroke risk. Review of migraine-associated pathophysiology. PMC. PMC11324503
• Bushnell CD et al. Migraine and stroke. Stroke. American Heart Association Journals. doi:10.1161/strokeaha.112.656603
• Schurks M et al. Migraine headache and ischemic stroke risk: an updated meta-analysis. PMC. PMC2900472
• Frontiers in Pain Research. Migraine is associated with a higher risk of ischemic and hemorrhagic stroke: an analysis of the All of Us database. 2025. PMC12521163