While headaches can have many different causes, some of them are related to hormones and it is within this group of causes that we sometimes see headaches influenced by BCPs.

Migraine headaches generally improve or stay the same on BCPs, but occasionally get worse. Those that improve do so primarily because the pill works to suppress the woman’s own ovarian function and hormones, creating a lower and more stable level of hormone in her bloodstream. This stability improves one aspect of migraine provocation.

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For those whose migraines stay the same, it is usually because the increased hormonal stability is not a strong enough factor in their own situation to suppress migraines.

For those women whose migraines worsen on BCPs, it is most often because their particular BCP is not successful in suppressing their ovarian function. Consequently, they still have all the normal monthly swings of hormones, but it is worse…they have the addition of the BCP hormone, making their hormonal peaks higher. Such women may benefit by switching to a stronger or longer half life BCP to more consistently suppress ovarian function.

Pre-existing menstrual headaches generally improve on BCPs, so long as the BCP is strong enough to suppress the woman’s ovarian function, but occasionally they get worse. In those cases of worsening menstrual headaches with BCPs, changing to a stronger progestin pill that will more consistently suppress ovarian function will frequently resolve the problem.

If a woman complains of headaches only during the “off week” of BCPs, other resolutions may be possible:

One way to resolve this problem is to shorten the “off week” from seven days to three days. The three days off is enough to provoke a menstrual flow, but about the time the hormone levels are low enough to provoke a headache, the woman restarts a fresh pack of BCPs. Depending on the strength and half life of the progestin, an even shorter time off may be needed.

Another way to resolve this problem is to eliminate the “off week” entirely. Using this technique, a woman would go directly from one pack of pills into the next, skipping the placebo pills or the “off week.” She won’t have a menstrual flow and won’t get menstrual headaches. After several months of this, she may experience some breakthrough bleeding which can be safely ignored if occasional. If she bleeds every day, then the BCPs can be stopped for 3 days to provoke a period and then restarted continuously for another few months. Medically, this is equivalent to taking the BCPs in the normal fashion, but avoids or minimizes the problem of menstrual headaches. This works best with higher dose progestins and longer half life progestins, particularly if the woman occasionally is late or skips pills.

If headaches persist on the BCPs and alternative formulations or dosage schedules fail to resolve the problem, the BCPs will generally be stopped.

Women who experience migraine headaches preceded by an aura have been found to have an increased risk of stroke, particularly in the presence of other risk factors such as smoking. Some physicians recommend that because of this risk, these women should never use combination oral contraceptive pills, which may further increase the risk of stroke. Others disagree, believing that this should be an individualized risk/benefit assesment for each patient. Most are in agreement that progestin only pills may be safely used among these women.