1) For patients who mainly have migraines associated with menstrual cycles- and the occasional migraine triggered by stress. Would the primary treatment be COC- i.e lolo, alesse? If they do not want to start a contraceptive medication what is the next best option?
Yes, that is a viable option. Alternatively can try the "menstrual migraine prophylaxis protocol" whereby the patient takes EC-NAPROXEN 500mg PO BID -2/+3 days related to the anticipated date of menstruation. Obviously this works if the person is "regular" and on schedule every month. In summary it would mean taking b.i.d. naproxen for a total of 5 days or (10 tablets) monthly; 2 before and 3 days into the menstruation. You can alternate naproxen with frovatriptan or naratriptan which are "slower onset" triptans which tend to work better for this clientele who usually have a longer more protracted course.
2) I have 27 yr old female patient on OCP who has a history of migraines, and recently started to develop aura with her migraines. Do I need to stop her OCP ?
Not uncommon to develop visual aura with estrogen containing compounds – in fact I have seen it de novo with OCP, with HRT and in pregnancy. I usually educate the patient about the negligibly increased relative risk of stroke and make a joint decision (stroke risk is about 2-3 per 100,000– which in a young female demographic, non-smoker with no other cardiovascular risk factors is extremely low). Usually if younger no other risk factors I have been tending to keep the OCP on board, however the patient – or physician is overly anxious then switch to progesterone only or barrier contraception. In > age of 35, smoker or menopausal – would avoid estrogen.