Commentary|Videos|September 14, 2026

Migraine, Estrogen, and Pregnancy Shape Stroke Risk in Women

Fact checked by: Sydney Jennings

Rodica Di Lorenzo, MD, explains why new headaches, migraine with aura, estrogen exposure, smoking, and pregnancy matter in stroke assessment.

Stroke produces the same focal neurologic signs in women and men, but sex-specific exposures and reproductive history can change a patient’s underlying risk, Rodica Di Lorenzo, MD, a vascular neurologist at Cleveland Clinic, explained in a recent interview with Patient Care Online. Her message for primary care clinicians is to avoid reflexively labeling a new or changed headache or transient neurologic symptom as migraine, particularly in patients who are pregnant or use estrogen-containing contraception.

Migraine history requires specificity. Clinicians should distinguish migraine with aura from migraine without aura and ask whether the current headache differs from the patient’s established pattern. The CDC’s 2024 US Medical Eligibility Criteria classifies combined hormonal contraceptive use as category 4—an unacceptable health risk—for patients with migraine with aura. It also states that any new headache or marked change in headache should be evaluated.¹

Pregnancy and the postpartum period add a separate set of risks. CDC guidance identifies hypertensive disorders of pregnancy, including preeclampsia, as major contributors to pregnancy-associated stroke and notes that pregnancy-related physiologic changes increase thrombotic risk.² A 2026 American Heart Association and American Stroke Association scientific statement similarly emphasizes prevention before conception, prompt recognition of maternal stroke, and treatment decisions that account for both maternal and fetal health.³

In practice, clinicians should document aura status, contraceptive formulation, smoking, blood pressure, obesity, diabetes, pregnancy status, and timing relative to delivery when assessing headache or focal neurologic symptoms. A sudden severe headache, a headache with a new pattern, or headache accompanied by weakness, aphasia, visual loss, altered mental status, seizure, or marked imbalance requires urgent evaluation for secondary causes.

In the video above, Di Lorenzo gives a focused reminder to PCPs: common diagnoses such as migraine should remain diagnoses of fit. When the pattern changes or vascular and reproductive risks accumulate, stroke and other cerebrovascular emergencies need to move higher on the differential.

Di Lorenzo has no relevant disclosures.


References

1. Centers for Disease Control and Prevention. Appendix D: Classifications for Combined Hormonal Contraceptives. US Medical Eligibility Criteria for Contraceptive Use, 2024. Updated November 19, 2024. https://www.cdc.gov/contraception/hcp/usmec/combined-hormonal-contraceptives.html

2. Centers for Disease Control and Prevention. About Pregnancy and Stroke. Updated May 19, 2026. Accessed September 14, 2026. https://www.cdc.gov/stroke/about/pregnancy-and-stroke.html

3. Miller EC, Bello NA, Chen PR, et al. Prevention and Treatment of Maternal Stroke in Pregnancy and Postpartum: A Scientific Statement From the American Heart Association and American Stroke Association. Stroke. 2026;57:e127-e145. doi:10.1161/STR.0000000000000514


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