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Table 5 Statements with the strength of the recommendation and the quality of evidence

From: Hormonal contraceptives and risk of ischemic stroke in women with migraine: a consensus statement from the European Headache Federation (EHF) and the European Society of Contraception and Reproductive Health (ESC)

Statement Strength Quality of evidence
1 In women who are seeking hormonal contraception, we recommend a clinical evaluation for the presence of migraine, for the definition of migraine subtype (i.e., with or without aura) and migraine frequency together with the ascertainment of conventional vascular risk factors before prescription of combined hormonal contraceptives 1, Strong C, Low
2 In women who are seeking hormonal contraception, we recommend the use of a dedicated, easy-to-use tool to diagnose migraine and its subtypes (i.e., with and without aura) 1, Strong C, Low
3 In women who are seeking hormonal contraception, we recommend consideration of the type of hormonal contraception taking into account their influence on the risk of ischemic stroke as there are high risk products (combined oral contraceptives containing >35 μg ethinylestradiol), medium risk products (combined oral hormonal contraceptives containing ≤35 μg ethinylestradiol, combined contraceptive patch, and combined vaginal ring) and no risk products (progestogen-only contraceptives including oral pill, subdermal implant, depot-injection, and levonorgestrel-releasing intrauterine system) 1, Strong B, Medium
4 In women with migraine with aura who are seeking hormonal contraception, we suggest against prescription of combined hormonal contraceptives (oral pill, transdermal patch, and vaginal ring) containing ethinylestradiol and 17β-estradiol/estradiol valerate 2, Weak C, Low
5 In women with migraine with aura who are seeking contraception we suggest non-hormonal contraception (condoms, copper-bearing intrauterine device, permanent methods) or progestogen-only contraceptives (oral pill, subdermal implant, depot-injection, and levonorgestrel-releasing intrauterine system) as the preferential option 1, Strong C, Low
6 In women with migraine with aura who are already using combined hormonal contraceptives for contraception, we suggest switching to non-hormonal contraception (condoms, copper-bearing intrauterine device, permanent methods) or progestogen-only contraceptives (oral pill, subdermal implant, depot-injection, and levonorgestrel-releasing intrauterine system) 2, Weak C, Low
7 In women with migraine without aura who are seeking hormonal contraception and who have additional risk factors (cigarette smoking, arterial hypertension, obesity, previous history of cardiovascular disease, previous history of deep vein thrombosis or pulmonary embolism), we suggest non-hormonal contraception (condoms, copper-bearing intrauterine device, permanent methods) or progestogen-only contraceptives (oral pill, subdermal implant, depot-injection, and levonorgestrel-releasing intrauterine system) as the preferential option 2, Weak C, Low
8 In women with migraine without aura who are seeking hormonal contraceptives and who have no additional risk factors (cigarette smoking, arterial hypertension, obesity, previous history of cardiovascular disease, previous history of deep vein thrombosis or pulmonary embolism) we suggest the use of combined hormonal contraceptives containing ≤35 μg dose of ethinylestradiol as a possible contraceptive option with monitoring of migraine frequency and characteristics. Benefits and risk of combined hormonal contraceptives use in comparison to other contraceptive options have to be balanced carefully 2, Weak C, Low
9 In women with migraine with aura or migraine without aura who require hormonal treatment for polycystic ovary syndrome or endometriosis we suggest to select the hormonal treatment of choice (progestogen-only or combined hormonal contraceptives) on clinical grounds 2, Weak C, Low
10 In women who start combined hormonal contraceptives for contraception and who develop new onset of migraine with aura, or who develop new onset migraine without aura in a temporal relationship to starting the hormonal contraceptive, we suggest switching to non-hormonal contraception (condoms, copper-bearing intrauterine device, permanent methods) or progestogen-only contraceptives (oral pill, subdermal implant, depot-injection, and levonorgestrel-releasing intrauterine system). 2, Weak C, Low
11 In women with migraine with or without aura who require emergency contraception, we suggest the use of levonorgestrel 1.5 mg orally, ulipristal acetate 30 mg orally, or the copper-bearing intrauterine device 2, Weak C, Low
12 In women with migraine with or without aura seeking hormonal contraception, we suggest against specific tests (e.g. thrombophilia screening, patent foramen ovale evaluation or neuroimaging evaluation) to decide about hormonal contraceptive prescription unless those tests are indicated by the patient’s history or by the presence of specific symptoms 2, Weak C, Low
13 In women with non-migraine headache who are seeking hormonal contraception any low-dose hormonal contraceptive can be used 2, Weak C, Low