Here’s why I care about your migraines


I prescribe a lot of birth control. A LOT. Not surprising – over 60% of college students use The Pill as a form a birth control, and they have to get it from somewhere, right?

There are some things I have to ask about when you come to me for a pill prescription. Medical history, smoking history, menstrual history, sexual history. And I’ll ask you whether you have a history of migraines.

Common response: “Not too often” – said chirpily, almost dismissively. So…that’s a yes, then?

As you may or may not have heard, “migraine” is not synonymous with “really bad headache”. So: Step 1 for me here is to filter out the “bad headaches” from the actual migraines. Step 2 is to figure out whether the people with real migraines have migraine with aura.

If the answer is “NO” to either of those first two questions, we can stop talking about them. And please, keep in mind that I’m not dismissing or minimizing the burden that headaches place on your life here. Headaches are super lame, I couldn’t agree more. I’m no fan of headaches myself! Moreover, I’m sure yours are terrible.

But you didn’t come here today to talk about your headaches, right?

The reason I’m asking is because if you keep answering “yes” through steps 1 and 2, and if I then verify that what you’re describing as “aura” before your migraines are, in fact, aura, there’s a very good chance you won’t be leaving with that prescription refill today.

Why? Oh, only because every organization with a vested interest in either headaches or contraception has issued statement after statement that combined oral contraceptives are absolutely contraindicated for women who get migraines with aura. Contraindicated means DO NOT PRESCRIBE.

If you’re coming to see me to talk about starting birth control for the first time, this is typically not major news. You weren’t particularly attached to the pill, anyhow. And IUDs sound pretty good, now that I mention it. Or maybe even Depo! Who wants to have to take a pill every day, anyhow? Such a pain. What I’m saying is, you’re usually more open to options if you haven’t already fallen in love with your current method.

But when you’re like the girl I just saw today, who has been getting migraines with aura since high school, and who has been ON THE PILL since high school – both which were managed by her beloved family pediatrician/PCP/gynecologist – you’re going to look at me like I just grew a second head when I talk to you about stopping the pill. And since you’ve always felt that they really shouldn’t be giving prescription-writing licenses to people with two heads (which seems more than a little unfair, btw) I am clearly unfit to give medical advice.

Look. I’m not trying to find excuses to not give you your birth control. In fact, I was more than happy to step right in and refill your prescription when your provider at home refused just because you hadn’t come in for that yearly-pap-you-don’t-really-need. I’m all about talking up IUDs for young adults to anyone who will listen. I’m really, truly, enthusiastically pro-contraception-for-all. But I can’t just un-read the piles of medical evidence that tell me that continuing your estrogen-containing contraceptive pill puts you at an uncomfortably high risk of stroke. Really, you’re a healthy 20-year-old. There are essentially zero reasons why you should be having a stroke. And I don’t want to be the provider that gives you one.

Why has no one ever mentioned this to you before, you ask?

This is a good question. One that, perhaps, you should be asking them.

In fact, in all seriousness, I really would like to ask them myself. And if they can show me the evidence base that supports their statement to you that staying on the pill “should be fine” (sounds convincing), I would be happy to reconsider my position.

Until then, if you’re open to it, I’d be delighted to talk to you about the wide, wonderful world of non-estrogen-containing contraception. LET’S TALK.


4 thoughts on “Here’s why I care about your migraines

  1. Pingback: Migraine Update — Tips For Easing the Nightmare | Mrs. City Boy

  2. I’ve basically read your whole blog in one day so needless to say I love the content and I love what you have to say. I feel like questions regarding migraine & aura is so frequently neglected/overlooked! I had migraines w/aura through my 20s and was never asked this question and always prescribed OCPs.

    • I couldn’t agree more; it drives me nuts how often prescribers overlook migraines with aura – or don’t even think to ask about it – when prescribing OCPs. Total pet peeve. Here’s to proactive and informed patients and providers!

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