A 32-year-old wishes to start a combined oral contraceptive pill (COCP). She is a non-smoker, BMI 24, migraines with aura. Her mother had DVT. Which WHO Medical Eligibility Criterion (MEC) category applies to migraine with aura, and what does it mean for prescribing COCPs?
- A MEC Category 2; benefits generally outweigh risks, COCP can be used with caution
- B MEC Category 3; risks generally outweigh benefits, usually not used
- C MEC Category 4; absolute contraindication, COCP must not be used ✓
- D MEC Category 1; no restriction on use
Explanation
WHO MEC 2015 classifies migraine with aura as Category 4 for combined hormonal contraceptives — an absolute contraindication. Aura represents focal neurological symptoms (cortical spreading depression), and oestrogen in COCPs increases thromboembolic and ischaemic stroke risk, which is substantially amplified in women with migraine with aura (RR for ischaemic stroke ~8× in combined risk). Family history of DVT in a first-degree relative is WHO MEC 2 for COCPs. Therefore, this patient's migraine with aura is the decisive contraindication. Progestogen-only methods (pills, implant, LNG-IUS) remain WHO MEC 2 for migraine with aura and are acceptable alternatives.
Reference: Shaw's Textbook of Gynaecology, 17th ed.
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Written and medically reviewed by the StethoPrep medical team.