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As a sufferer from ‘classic’ migraine with aura from the age of 15 years, who has in the past used a combined oral contraceptive pill during my 30s, I read Anne MacGregor's review article1 with great interest. Safe prescription of contraception for those of us who suffer from migraine has to be important, and this article promised clarification and assistance. In my case, my general practitioner didn't include aura symptoms as any determinant of medication, although, to be fair, this was 20 years ago when the links between aura, combined hormonal contraception (CHC) and ischaemic stroke presumably weren't clear.
The article begins by setting out two risk factors for ischaemic stroke prevalent in women aged 16–49 years, namely CHC and migraine aura. The article goes on to point to incorrect identification of migraine aura symptoms as a factor in withholding CHC, and to advocate more precise identification of aura symptoms in order that CHC may not be unnecessarily withheld.
The article identifies two diagnostic tools for migraine with and without aura: ID-Migraine™ and the visual aura rating scale (VARS). The tools are described and helpfully replicated in the article, and the author also suggests ‘additional tips’ in using the VARS that help to shore up a reliable diagnosis.
This is useful information as far as it goes, but I was left wondering whether the author is firmly recommending these tools, either singly or in combination (or together with the ‘additional tips’)? If so, a step-by-step flowchart outlining the tools' use might have been a useful extension, to guide practitioners in their application to arrive at a robust diagnosis. I also thought the case study, which demonstrated the importance of asking the patient the right questions, could have gone further to demonstrate the use of these diagnostic tools.
In summary, as a migraine sufferer and previous user of contraception I welcome the author's attempt in this review article to aid safe prescribing practice of CHC for migraine sufferers. Given that the links between aura and ischaemic stoke are now established, I hope that primary care practitioners will find this article sufficient to aid their practice. Perhaps they could construct their own differential diagnostic tool as a hybrid of ID-Migraine, the VARS and the author's ‘additional tips’?
Competing interests None declared.
Provenance and peer review Commissioned; internally peer reviewed.
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