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

If you get migraines with aura-those flickering lights, blind spots, or tingling sensations before the headache hits-you’ve probably been told to avoid birth control pills with estrogen. And for good reason. The risk of stroke goes up. But is it as dangerous as they say? And what if you’re on a low-dose pill today, not the high-dose ones from the 1970s? The answer isn’t simple. It’s messy, personal, and depends on more than just your migraine type.

What Exactly Is Migraine with Aura?

Migraine with aura isn’t just a bad headache. It’s your brain sending warning signals-usually visual-before the pain starts. You might see zigzag lines, flashing lights, or blind spots. Some people feel numbness in their hand or face, or even trouble speaking. These symptoms last 5 to 60 minutes and happen before the headache, or sometimes at the same time. It’s not nausea, sensitivity to light, or fatigue-that’s just a migraine prodrome. Aura is neurological. And it’s the difference between a manageable headache and a potentially dangerous one when combined with estrogen.

Why Estrogen Makes Things Riskier

Estrogen in birth control pills affects blood clotting. It makes your blood a little thicker. For most women, that’s fine. But if you have migraine with aura, your brain is already more vulnerable to small blood vessel changes. Add estrogen, and the risk of a clot forming in the brain-leading to an ischemic stroke-goes up sharply.

Here’s the numbers: Healthy young women without migraines have about a 6 in 100,000 chance of having a stroke each year. If you have migraine with aura and take a combination pill with estrogen, 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. That’s not a small number. It’s why the World Health Organization says: don’t use estrogen-containing birth control if you have migraine with aura.

The New Debate: Are Low-Dose Pills Safer?

But here’s where it gets complicated. The warnings were based on pills from decades ago-50 to 100 micrograms of estrogen. Today’s pills are different. Most contain 20 to 35 micrograms. Some new ones have as little as 10 to 15. And some doctors are starting to question if the old rules still apply.

A 2022 study from Dr. Pinar Batur’s team at the American Migraine Foundation looked at women with migraine with aura who used low-dose estrogen pills. They found the stroke risk wasn’t as high as expected. The study had only 127 women with confirmed strokes, so it’s small. But it’s one of the first to suggest that modern, ultra-low-dose pills might be safer than we thought.

Dr. Anne Calhoun, a headache specialist, argues that the fear comes from outdated data. “We’re still treating women as if they’re on 1970s birth control,” she says. Her review points out that low-dose pills (20-25 micrograms) might not raise stroke risk at all-and could even reduce aura frequency by stabilizing hormone drops around your period.

Still, the WHO hasn’t changed its stance. Neither has the CDC. And for good reason: the evidence isn’t solid enough. We don’t have large, long-term studies tracking women on 10-15 microgram pills over 10 years. Until we do, the safest advice remains: avoid estrogen if you have aura.

What About Migraine Without Aura?

If you get migraines but no aura-just the headache, nausea, light sensitivity-you’re in a different category. Multiple studies show estrogen-containing birth control doesn’t significantly raise your stroke risk. The CDC confirms this. For these women, combination pills are still an option, especially if they don’t smoke, have normal blood pressure, and are under 35.

The key is knowing your type. Many women think they have “just migraines,” but if they’ve ever had visual disturbances, flashing lights, or numbness, they likely have aura. Don’t guess. Write down your symptoms. Talk to your doctor. Getting this right matters.

How Often Do You Get Migraines? Frequency Matters

It’s not just about aura. How often you get attacks changes the risk too. If you have more than 12 migraines a year-with or without aura-your stroke risk jumps. One study found women with frequent attacks had over 10 times the risk of stroke compared to those with fewer than one per month.

Even monthly migraines can be risky if they’re severe. But if you only get one or two a year, and they’re mild, your risk is much lower. Your doctor should ask: “How many days a month do you have headaches? Do you miss work or school because of them?”

Other Risk Factors You Can’t Ignore

Estrogen + migraine with aura is dangerous. But add smoking, high blood pressure, obesity, or a family history of stroke, and the risk multiplies. Smoking is especially bad. If you’re over 35, smoke, and have aura? Combination pills are absolutely off-limits. No exceptions.

Even if you don’t smoke, check your blood pressure. High blood pressure with migraine with aura is a red flag. If your numbers are above 140/90, you need to avoid estrogen entirely. Diabetes or a history of blood clots? Same thing.

What Are Your Alternatives?

Good news: you have options. And they’re safe.

• Progestin-only pills (mini-pills): No estrogen. Safe for migraine with aura. Must be taken at the same time every day.
• Levonorgestrel IUD (Mirena, Kyleena): Lasts 3 to 8 years. Releases tiny amounts of progestin locally. No systemic hormones. Very low risk.
• Etonogestrel implant (Nexplanon): A small rod under your skin. Works for 3 years. No estrogen.
• Depo-Provera injection: Given every 3 months. Progestin only.
• Copper IUD (Paragard): Non-hormonal. Lasts up to 12 years. No hormones at all.
• Barrier methods: Condoms, diaphragms. Lower effectiveness, but zero hormone risk.

These aren’t second choices. They’re first-line recommendations from the American College of Obstetricians and Gynecologists (ACOG) and the International Headache Society. And they work.

When Might a Doctor Still Recommend Estrogen?

There’s one exception: menstrual migraine. Some women only get migraines right before or during their period, when estrogen drops. For them, continuous birth control-skipping the placebo week-can prevent those attacks. If you’re one of them, and you’re young, healthy, non-smoking, and on a low-dose pill (under 30 micrograms), some doctors may consider it. But only after full discussion, documented risk factors, and signed consent.

It’s not standard. It’s off-label. And it’s rare. Most doctors won’t do it. But if you’ve tried everything else and your migraines are disabling, it’s worth talking about-with clear eyes on the risks.

What Should You Do Right Now?

Don’t panic. Don’t stop your pill cold turkey unless you’re having symptoms like sudden weakness, slurred speech, or vision loss-that’s a stroke warning. But do this:

1. Track your migraines. Use an app or journal. Note if you have aura, how often, and how long.
2. Know your numbers. Get your blood pressure checked. If you smoke, quit.
3. Ask your doctor: “Do I have migraine with aura? How many attacks a month? What’s my stroke risk with my current pill?”
4. Ask about alternatives. “What progestin-only options work best for me?”
5. Don’t assume. If you’ve been on the pill for years and just learned you have aura, talk to your doctor before your next refill.

The goal isn’t to scare you. It’s to empower you. You deserve birth control that works-and doesn’t put your brain at risk. The science is still evolving. But the safest path right now is clear: if you have aura, skip estrogen. Choose progestin. Or go non-hormonal. There are plenty of good options. You just need to find the right one for you.

When to Seek Emergency Help

If you’re on estrogen and experience any of these, call 999 or go to A&E immediately:

• Sudden, severe headache unlike any before
• Weakness or numbness on one side of your body
• Slurred speech or trouble understanding others
• Sudden vision loss in one or both eyes
• Dizziness, loss of balance, or sudden confusion

These aren’t migraine symptoms. These are stroke symptoms. Don’t wait. Don’t think it’s just a bad migraine. Act fast.