Abstract text (incl. figure legends and references)

Objective: Hormonal fluctuations during the menstrual cycle affect migraine frequency, duration and intensity. Use of combined oral contraception (COC) containing new generation of estrogen, COC with extended cycle as well as gestagen monotherapy (GM) can reduce the burden of disease. Access to hormonal contraception (HC) to women with migraine especially with aura (MA), has often been denied due to an increased risk of ischemic stroke. However, the absolute risk of ischemic stroke with the use of HC in migrane is minor and the prescription after informed consent is possible. We assessed the influence of migraine without aura (MO) and MA on the prescribing behavior of HC among German gynecologists and investigated potential factors influencing gynecologist"s decision-making process.

Method: In this descriptive observational study of practicing German gynecologists, prescription of HC in migraine was investigated using a self-administered online-based survey with up to 29 items from October 2021 to March 2022. The survey was distributed via mail and e-mail.

Results: A total of n=851 gynecologists responded to the questionnaire. Gynecologists regularly ask for MO (94.5%) and MA (91.8%) prior to prescribing HC. In the presence of MO, 75% of participants reported to prescribe COC only under certain conditions, with cardiovascular risk factors and other comorbidities particularly influencing the decision. In contrast, GM is prescribed in MO by 82% of participating gynecologists without restrictions. In MA, 90% of gynecologists do not prescribe COC at all and 47% of gynecologists stated to not prescribe GM or do so only under certain conditions. Almost all gynecologist reported to have initiated (80%), discontinued (95.8%) or changed (99.2%) a HC due to migraine.

Conclusion: Although HC is not generally contraindicated in migraine patients, presence of MA but also MO hinder German gynecologists to prescribe HC.