Primary headache disorders such as migraine affect almost a third of women during their childbearing years, when decisions about contraception must be made. Headache is also a commonly reported adverse event in clinical trials of oral contraceptives (OCs). Health care practitioners will frequently be called upon to give advice about the use of OCs to women with headache. This article applies current evidence, guidelines, and recommendations about headache and OC use to treatment decisions in four clinical scenarios: initiating OC use in a woman who has migraine without aura, continuing OC use in a woman who experiences worsening of migraine and the development of aura after initiating OCs, initiating OC use in a woman with tension-type headache (TTH) and a family history of migraine, and use of an extended duration OC regimen to minimize migraine triggered by estrogen withdrawal. The authors' recommendations regarding OC use in various primary headache disorders are summarized.