Abstract
We thank Drs Driul and Londero for their interest in our study.1Champaloux S.W. Tepper N.K. Monsour M. et al.Use of combined hormonal contraceptives among women with migraines and risk of ischemic stroke.Am J Obstet Gynecol. 2017; 216: 489.e1-489.e7Abstract Full Text Full Text PDF Scopus (59) Google Scholar We agree that thrombogenic mutations may be a contributing factor in migraine-related stroke. We did not adjust for known thrombogenic mutations; however, because combined hormonal contraceptives (CHCs) are not recommended for use by women with known thrombogenic mutations because of safety concerns,2Curtis K.M. Tepper N.K. Jatlaoui T.C. et al.US medical eligibility criteria for contraceptive use, 2016.MMWR Recomm Rep. 2016; 65: 1-103Google Scholar we expect that there would be only a small number of women with those disorders who use CHCs. Our analysis adjusted for the important confounders mentioned by Drs Driul and Londero, namely age, hypertension, smoking, and obesity as well as others that included diabetes mellitus, ischemic heart disease, and valvular heart disease, while noting the potential for misclassification from the use of healthcare claims data. Because of the use of healthcare claims data, we could not assess migraine or aura frequency. Although there is some evidence that migraine frequency impacts stroke risk,3Kurth T. The association of migraine with ischemic stroke.Curr Neurol Neurosci. 2010; 10: 133-139Crossref PubMed Scopus (25) Google Scholar it is not clear whether aura frequency is related to stroke risk; these associations warrant further study. We agree that the mechanism of ischemic stroke related to migraine with aura is not well understood and probably involves multiple mechanisms.3Kurth T. The association of migraine with ischemic stroke.Curr Neurol Neurosci. 2010; 10: 133-139Crossref PubMed Scopus (25) Google Scholar The pathways may include cerebral hypoperfusion related to the aura, arterial dissections, patent foramen ovale, or the presence of vascular risk factors.3Kurth T. The association of migraine with ischemic stroke.Curr Neurol Neurosci. 2010; 10: 133-139Crossref PubMed Scopus (25) Google Scholar Although these complex mechanisms need to be further clarified, migraine with aura is associated independently with an increased risk of ischemic stroke.3Kurth T. The association of migraine with ischemic stroke.Curr Neurol Neurosci. 2010; 10: 133-139Crossref PubMed Scopus (25) Google Scholar Given that CHCs are also associated with an elevated risk of ischemic stroke, even at lower doses of ethinyl estradiol (including 20 μg),4Xu Z. Li Y. Tang S. Huang X. Chen T. Current use of oral contraceptives and the risk of first-ever ischemic stroke: a meta-analysis of observational studies.Thromb Res. 2015; 136: 52-60Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar and that stroke is a devastating event, concerns remain about the use of CHCs in women who experience migraine with aura. Based on current understanding of mechanisms, it is not clear that there are subgroups of women with migraine with aura (eg, women without a thrombogenic mutation) for whom CHCs would not further elevate the risk of stroke to an unacceptable level.2Curtis K.M. Tepper N.K. Jatlaoui T.C. et al.US medical eligibility criteria for contraceptive use, 2016.MMWR Recomm Rep. 2016; 65: 1-103Google Scholar In addition, the prevalence of thrombogenic mutations is low, and the cost of screening is high; therefore, screening is not recommended before considering whether to use CHCs.2Curtis K.M. Tepper N.K. Jatlaoui T.C. et al.US medical eligibility criteria for contraceptive use, 2016.MMWR Recomm Rep. 2016; 65: 1-103Google Scholar Future studies are needed on the pathophysiology and magnitude of risk of stroke related to migraine, hormonal contraceptives, and other stroke risk factors. Such research would contribute to better understanding the safety of hormonal contraceptive use among women with migraine. Healthcare providers should counsel women about risks, benefits, and alternatives so that women can make informed decisions about contraceptive method choice. Use of combined hormonal contraceptives among women with migraines and risk of ischemic strokeAmerican Journal of Obstetrics & GynecologyVol. 216Issue 5PreviewMigraine with aura and combined hormonal contraceptives are independently associated with an increased risk of ischemic stroke. However, little is known about whether there are any joint effects of migraine and hormonal contraceptives on risk of stroke. Full-Text PDF
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