What is the most preferred combined oral contraceptive pill (COCP) for a patient with migraine without aura that has the least side effects?

From the Guidelines

For patients with migraine without aura, a low-dose combined oral contraceptive pill containing ethinyl estradiol 20-30 mcg with a second or third generation progestin (such as levonorgestrel, norethindrone, or norgestimate) is generally preferred.

Key Considerations

• Specific options include Loestrin Fe (20 mcg ethinyl estradiol/1 mg norethindrone), Alesse or Aviane (20 mcg ethinyl estradiol/0.1 mg levonorgestrel), or Ortho-Cyclen (35 mcg ethinyl estradiol/0.25 mg norgestimate) 1.
• These lower-dose formulations typically cause fewer side effects while maintaining contraceptive efficacy.
• It's essential to monitor patients closely as migraine frequency may change with hormonal contraception.
• If migraines worsen or develop aura, the COCP should be discontinued immediately as this significantly increases stroke risk.

Side Effects and Monitoring

• Starting with the lowest effective dose helps minimize common side effects like nausea, breast tenderness, and mood changes.
• Monophasic pills (same hormone dose throughout the cycle) may provide more stable hormone levels and potentially fewer side effects than multiphasic formulations.
• Regular follow-up at 3 months is recommended to assess tolerability and migraine patterns 1.

Additional Guidance

• The most recent study 1 does not directly address the question but provides general guidance on hormonal replacement therapy, which may be relevant in certain contexts.
• However, for the specific question of COCPs in patients with migraine without aura, the guidance from 1 and 1 is more directly applicable.
• It's crucial to weigh the benefits and risks of COCPs in each patient, considering factors such as migraine history, other medical conditions, and the potential for side effects.

From the Research

Combined Oral Contraceptives for Migraine Without Aura

• The use of combined oral contraceptives (COCPs) in patients with migraine without aura is generally considered safe, but it's essential to carefully evaluate individual risk factors 2, 3.
• COCPs with lower doses of estrogen (less than 30 μg of ethinyl estradiol) are preferred, as they may help prevent menstrual migraine and reduce the frequency of aura 3, 4.
• The risk of ischemic stroke is not significantly increased with the use of COCPs in patients with migraine without aura, but other risk factors such as tobacco use, hypertension, and hyperlipidemia should be carefully considered 2, 5.
• The exclusion of hereditary thrombophilia and alterations of coagulative parameters should precede any decision to prescribe COCPs in patients with migraine 2.

Preferred COCP Formulations

• Ultra-low-dose formulations (less than 20 μg of ethinyl estradiol) may be beneficial in preventing menstrual migraine and reducing the frequency of aura 3.
• Formulations containing ≤30 μg EE are preferred when using COCPs in patients with migraine, even those without aura 4.
• The principle of prescribing the lowest dose with the least side effects should be followed when selecting a COCP for patients with migraine without aura 6.

Important Considerations

• Determining migraine type is critical in assessing the safety of COCPs among women with migraine 5.
• Shared decision-making should include discussions about ischemic stroke risks in patients with migraine, even those without aura 4.
• Patients should be educated on how to manage their pill-taking and be responsible for their medication and prevention follow-up 6.