Avoid casual prescribing of estrogen-containing contraception in migraine with aura, document the vascular risk discussion, and investigate late-onset aura aggressively for secondary cardioembolic or structural causes.

Migraine with aura substantially increases ischemic stroke risk; Combined hormonal contraception further amplifies stroke risk in migraine with aura; PFO-related microembolism is one proposed mechanism for aura generation; Endothelial activation markers support a proinflammatory and procoagulant model; Late-onset aura warrants broader secondary and vascular evaluation