The following are key points to remember from this teaching case study on oral contraceptives and ischemic stroke risk:

1. Modern combined oral contraceptive pills (OCPs) have a lower dose of estrogens and less risk of stroke than older contraceptive formulations.
2. The risk of ischemic stroke in patients using combined oral contraceptives is increased in patients with additional stroke risk factors, including smoking, hypertension, and migraine with aura.
3. The risk of ischemic stroke because of combined OCPs is less than the risk associated with pregnancy.
4. Clinicians should consider the constellation of stroke risk factors in concert with OCP formulation to determine individual stroke risk and the best contraceptive to reduce that risk in an individual woman.
5. Data linking stroke and OCP use in patients with migraine are limited and conflicting.
6. International Headache Society guidelines find no contraindications to combined OCP use in patients who have migraine without aura or lack other stroke risk factors (i.e., diabetes, hyperlipidemia, hypertension, smoking, and obesity).
7. While these guidelines warn of a potential increased risk of stroke in patients who have migraine with aura, there are no specific guidelines to not use OCPs in these patients.
8. Use of nonestrogen contraception, such as an intrauterine device (IUD), progestin injections, or progestin implant, is recommended for women with multiple risk factors for stroke.
9. The American College of Obstetricians and Gynecologists guidelines further recommend that clinicians consider progestin-only (pill, IUD, injection, and implant) or nonhormonal (copper IUD, surgery, and barrier) contraceptive methods to women with migraine with focal neurological signs (for example, hemiplegic migraine), women ≥35 years of age, and smokers.
10. Careful follow-up and communication regarding contraceptive choices can prevent the morbidity and mortality risk associated with both ischemic stroke and unintended pregnancy.

Keywords: Brain Ischemia, Contraception, Contraceptives, Oral, Combined, Diabetes Mellitus, Estrogens, Female, Headache, Hemiplegia, Hyperlipidemias, Hypertension, Intrauterine Devices, Migraine without Aura, Migraine with Aura, Obesity, Pregnancy, Pregnancy, Unplanned, Primary Prevention, Progestins, Risk Factors, Smoking, Stroke, Vascular Diseases

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