Contraception Counseling OSCE - Contraception in Migraine Patient

Case Overview

• Age/Sex: 29-year-old female
• Occupation: Office worker (project manager)
• Setting: Primary care / sexual health clinic
• Chief complaint: "I want to discuss contraception"

Patient Script

Who I Am

I'm 29, I work in an office doing project management, and I'm pretty stressed at the moment.

What Brings Me In

I want to talk about starting contraception — my boyfriend and I are sexually active and I don't want to get pregnant right now.

My Story

I've had migraines since I was a teenager, maybe since about age 16. For me the migraines usually start with a kind of visual disturbance — flashing lights and zigzag lines in my right visual field that last about 20–30 minutes. After that I get a bad headache that is usually one-sided, throbbing, with nausea and light sensitivity, and it can last a day or so. This usually happens about once a month. I used to take sumatriptan when they’re bad; I take it only a few times a month. My last severe migraine was two weeks ago. My periods are fairly regular every 28–32 days and I’m not trying to get pregnant.

I tried the combined pill in university for a couple of years but stopped because it made me feel low and a bit anxious. I haven’t used any regular hormonal contraception since then. I’m worried about side effects and about doing the right thing because of my headaches.

My Medical Background

• Past medical history: Migraine with aura since adolescence
• Medications: Sumatriptan 50 mg as needed (rarely more than 2–3 times/month); occasional paracetamol
• Mental health: Mild anxiety, coping but under stress at work
• Allergies: None known
• Sexual history: In a monogamous relationship, sometimes use condoms, not planning pregnancy
• Smoking/alcohol/drugs: Stopped smoking 2 years ago; drinks 1–2 glasses of wine at weekend; occasionally uses cannabis socially (1–2 times/month)
• Family history: Mother alive, well; maternal aunt had a DVT in her 50s (treated), no family history of early stroke

What I Think & Worry About

• I think my headaches might be affected by hormones and I worry taking a pill could make my migraines worse.
• I’m scared about the risk of stroke — I’ve heard hormones can cause that with migraines.
• I don’t want anything that will make me gain weight or worsen my anxiety.

If You Ask Me About Other Symptoms...

• Headache details: I get visual aura (flashing, zigzag) for ~20–30 minutes then the headache; nausea and light sensitivity are common; no weakness or numbness during attacks.
• Neurology: I haven’t had any weakness, speech problems, or collapse with my headaches.
• Bleeding: My periods are regular and not excessively heavy.
• Contraceptive preferences: I prefer something low-maintenance and very effective, but I’m worried about weight gain and mood effects.
• Previous contraception: I stopped the combined pill because it made me feel low; I didn’t have blood clots when I was on it.
• Recent events: No recent long flights, no known pregnancy, no current infections.

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Clinical Summary

Examination

• General: Alert, cooperative female, appears well
• Vitals: Blood pressure 118/72 mmHg; heart rate 78 bpm; afebrile
• BMI: 24 kg/m2
• Neurological exam: Cranial nerves intact; normal visual fields to confrontation; no focal weakness; gait normal
• Cardiovascular: Heart sounds normal, no murmurs
• Abdominal/pelvic: Abdomen soft, non-tender (no routine pelvic exam findings required for this station)

Investigations

• Urine pregnancy test: Negative (no current pregnancy)
• Full blood count: Hb 13.0 g/dL (normal)
• Blood pressure: 118/72 mmHg (normal)
• Thrombophilia screen: Not done (no personal history of VTE; family history only of aunt with DVT in her 50s)
• If considered: Lipid profile and glucose not required immediately given age and normal BMI, but consider baseline if starting certain methods

Diagnosis

• Primary: Contraception counseling in a patient with migraine with aura — combined estrogen-containing hormonal contraceptives are contraindicated because migraine with aura confers an increased risk of ischemic stroke when combined with estrogen-containing contraceptives.

  • Evidence: Clear history of visual aura lasting 20–30 minutes preceding typical migrainous headaches; age <35 but presence of aura is an independent risk factor making combined oral contraceptives inadvisable.

• Differentials / considerations:

  • Migraine without aura: less relevant here because patient clearly describes aura (visual phenomena) — important to distinguish because combined hormones are less strictly contraindicated in migraine without aura.
  • Tension-type headache or medication-overuse headache: less likely given recurrent aura and throbbing headaches; medication overuse unlikely given infrequent analgesic/triptan use.
  • Patient concerns about mood changes or weight gain from contraception: relevant to method selection rather than primary diagnosis.

Management

• Do not prescribe combined estrogen-containing contraceptives (COC or combined patch/ring) because of migraine with aura.
• Offer and discuss alternative effective options:
  • Progestin-only methods: progestin-only pill (POP) — suitability and adherence issues; implant (e.g., etonogestrel implant) — long-acting reversible; depot medroxyprogesterone injection — long-acting but potential for irregular bleeding and weight change.
  • Intrauterine devices: levonorgestrel IUD (highly effective, reduces menstrual bleeding) or copper IUD (non-hormonal option) — discuss pros/cons, insertion logistics.
• Address immediate practical steps:
  • Confirm no pregnancy (pregnancy test already negative) before starting long-acting method/insert IUD.
  • Discuss side effects: mood, bleeding pattern, weight changes; reassure about low stroke risk with progestin-only methods.
  • Counsel about method efficacy, reversibility, STI protection (condoms for STI prevention), and follow-up plan.
  • If patient prefers a method that previously caused mood changes (combined pill), explain why it is not recommended and offer trial of progestin-only alternatives instead.
• Safety netting:
  • Advise to seek urgent review if she develops new focal neurological signs (weakness, slurred speech, altered consciousness) or a change in her aura pattern.
  • Document migraine history and contraception discussion in notes; consider liaison with neurology if migraine frequency/severity changes significantly or if aura pattern evolves.

Key Learning Points

• Migraine with aura is an independent contraindication to combined estrogen-containing contraception because of increased ischemic stroke risk; progestin-only and intrauterine options are preferred.

• Always take a clear headache history to distinguish migraine with aura from migraine without aura or other headache types — the presence of transient focal neurological symptoms (visual scintillations, hemianopic phenomena, sensory or language symptoms) is crucial.

• Before starting a contraceptive method, exclude pregnancy, assess blood pressure, review VTE and cardiovascular risk factors, discuss preferences and side effects, and provide safety-netting advice for new neurological symptoms.