Suspected reversible cerebral vasoconstriction syndrome following ethinylestradiol-containing oral contraceptive use in a patient with migraine

Oestrogen-containing oral contraceptives (OCPs) are associated with increased cerebrovascular risk, particularly in individuals with migraine and vascular risk factors. ^1–3 Evidence regarding neurological complications of oestrogen use in transgender women remains limited. ^{4 5} We report a transgender woman with a history of migraine who presented with acute-onset severe retro-orbital headache followed by a generalised tonic-clonic seizure after initiating an ethinylestradiol-containing OCP for gender-affirming therapy. Initial neuroimaging demonstrated a left parietotemporal hypodensity interpreted as a possible cortical infarct. Following cessation of oestrogen therapy, the patient experienced complete clinical recovery, with resolution of the previously described imaging abnormality. This case illustrates the complex interplay between migraine, exogenous oestrogen and cerebrovascular risk. The presentation and disease course were most consistent with suspected reversible cerebral vasoconstriction syndrome associated with recent OCP exposure, although the diagnosis was not angiographically confirmed. Using the Naranjo adverse drug reaction probability scale, the association between the OCP and the neurological event was classified as possible rather than definite. ⁶ This case highlights the importance of careful risk assessment before oestrogen initiation and reinforces the need for safer hormone formulations in transgender healthcare.