A 34-year-old woman requests combined oral contraceptive pills. She reports recurrent unilateral throbbing headaches preceded by flashing zigzag lines lasting 30 minutes. Why are combined pills contraindicated in her?

• A Progestogens aggravate cortical spreading depression and precipitate status migrainosus
• B Oestrogen increases the risk of ischaemic stroke through a prothrombotic effect ✓
• C Combined pills reduce the efficacy of prophylactic beta blockers
• D Oestrogen raises intracranial pressure and can mimic idiopathic intracranial hypertension

Explanation

Migraine with aura is an absolute contraindication to combined hormonal contraception. Aura reflects transient cerebral hypoperfusion, and ethinyl oestradiol increases hepatic synthesis of clotting factors, producing a further rise in ischaemic stroke risk above that conferred by aura alone. B progestin-only pill is acceptable because it lacks the prothrombotic oestrogen component. Option A is wrong because the concern is vascular risk, not worsening of the migraine itself.

Reference: Katzung Basic and Clinical Pharmacology, 15th ed.

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Written and medically reviewed by the StethoPrep medical team.