From the Guidelines
Women with migraines with aura should avoid estrogen-containing contraceptives and instead opt for progestin-only or nonhormonal methods to minimize their risk of stroke. The safest contraceptive options for these patients include progestin-only methods such as the depo-medroxyprogesterone acetate injection (Depo-Provera, 150mg intramuscularly every 3 months), progestin-only pills (norethindrone 0.35mg daily, taken continuously without breaks), the levonorgestrel intrauterine device (Mirena, Kyleena, or Skyla, effective for 3-7 years depending on the type), or the etonogestrel subdermal implant (Nexplanon, effective for up to 3 years) 1. Non-hormonal methods like copper IUDs (ParaGard, effective for up to 10 years) and barrier methods are also excellent choices.
The concern with estrogen-containing contraceptives stems from their prothrombotic effects, which can increase stroke risk approximately 2-4 fold in women with migraines with aura 1. This risk is particularly significant because migraine with aura itself is an independent risk factor for ischemic stroke. When counseling these patients, it's essential to note that progestin-only methods may actually help reduce migraine frequency and severity in some women, providing an additional benefit beyond contraception.
Some key points to consider when choosing a contraceptive method for women with migraines with aura include:
- Avoiding estrogen-containing contraceptives due to their increased risk of stroke
- Considering progestin-only methods, such as injections, pills, or intrauterine devices
- Non-hormonal methods, like copper IUDs and barrier methods, are also safe and effective options
- Shared decision-making is recommended to determine the best contraceptive choice and balance the risk of stroke from contraception and the risk of stroke with pregnancy 1.
In terms of specific guidance, the 2024 guideline for the primary prevention of stroke recommends that individuals with specific stroke risk factors, including migraine with aura, who are considering contraception, should use progestin-only or nonhormonal contraception to prevent the increased stroke risk associated with estrogen-containing contraception 1.
From the Research
Contraception in Migraines with Aura
- The use of combined hormonal contraception (CHC) in women with migraines, particularly those with aura, has been a topic of debate due to the potential increased risk of ischemic stroke 2, 3, 4, 5, 6.
- Studies have shown that the absolute risk of ischemic stroke with CHC use in women with migraines is low, and an individualized approach may be more appropriate than current guidelines 2, 5, 6.
- The risk of stroke associated with CHC use in women with migraines may be estrogen dose-related, with high-dose formulations having the highest risk 2, 5.
- Some studies suggest that the use of CHCs with low doses of estrogen (20-25 µg ethinyl estradiol) may not increase the risk of stroke in women with migraines with aura, and continuous ultra-low-dose formulations (10-15 µg EE) may even reduce aura frequency 6.
- Other risk factors, such as tobacco use, hypertension, hyperlipidemia, obesity, and diabetes, must be carefully considered when prescribing CHCs in women with migraines, particularly those over 35 years old 3, 4.
- Progestin-only contraceptives and the copper intrauterine device can be safely used in women with migraines, including those with aura 4.
Key Findings
- The available evidence suggests that the risk of stroke associated with CHC use in women with migraines with aura is low, but may be increased with high-dose estrogen formulations 2, 5.
- Individualized assessment of harms and benefits is necessary when considering CHC use in women with migraines with aura 5, 6.
- Accurate classification of a patient's headache type can avoid unnecessary restriction of effective contraceptive methods, particularly those containing estrogen 4.