What birth control options are safe for women with migraines?

Birth Control Options for Women with Migraines

Women with migraine with aura should avoid combined hormonal contraceptives due to significantly increased stroke risk, while progestogen-only methods are safe for all migraine patients. 1

Understanding the Risk

Migraine status significantly impacts contraceptive safety:

• Migraine with aura:

  • Combined hormonal contraceptives (CHCs) are contraindicated due to a 6-fold increased risk of ischemic stroke 2
  • This risk is significantly higher than with either risk factor alone
  • The American Heart Association/American Stroke Association explicitly recommends avoiding estrogen-containing contraceptives in women with migraine with aura 1

• Migraine without aura:

  • CHCs may be used with caution in the absence of other stroke risk factors
  • Additional risk factors (smoking, hypertension, age >35, etc.) warrant avoiding CHCs 1, 3

Safe Contraceptive Options

First-line options (safe for all migraine patients):

1. Progestogen-only methods 4:

   • Progestogen-only pills (POPs) like norethindrone or desogestrel
   • Levonorgestrel intrauterine device (IUD)
   • Etonogestrel implant
   • Depot medroxyprogesterone acetate (DMPA) injections

2. Non-hormonal methods:

   • Copper IUD
   • Barrier methods (condoms, diaphragm)
   • Fertility awareness methods

For migraine without aura only (with no other risk factors):

• Combined hormonal contraceptives (pills, patch, ring) may be considered
• Must be discontinued immediately if aura symptoms develop 1

Benefits of Progestogen-Only Methods

Beyond safety, progestogen-only contraceptives may offer additional benefits for migraine patients:

• Preliminary evidence suggests desogestrel 75μg may reduce migraine frequency, intensity, and analgesic use 4
• Stable hormone levels may positively influence nociceptive thresholds 4
• No increased risk of venous thromboembolism or ischemic stroke 4

Important Considerations and Monitoring

• Regular follow-up is essential to monitor for:

  • Changes in migraine pattern or new aura symptoms
  • Development of additional cardiovascular risk factors
  • Contraceptive effectiveness and side effects

• Warning signs requiring immediate discontinuation of CHCs (if used):

  • Development of aura in previously aura-free migraine
  • Worsening headache pattern that is recurrent, persistent, or severe 5
  • New focal neurological symptoms

Clinical Decision Algorithm

1. Determine migraine type:

   • Migraine with aura → Avoid all CHCs, use progestogen-only or non-hormonal methods
   • Migraine without aura → Proceed to step 2

2. Assess additional stroke risk factors:

   • Present (smoking, hypertension, age >35, etc.) → Avoid CHCs, use progestogen-only or non-hormonal methods
   • Absent → All contraceptive options available, but progestogen-only methods may be preferable

3. Consider impact on migraine management:

   • For menstrual-related migraine without aura → Continuous use of progestogen-only methods may help stabilize hormone levels
   • For frequent migraines → Consider progestogen-only methods that may reduce migraine burden

Pitfalls to Avoid

• Not distinguishing between migraine types: Failure to identify aura can lead to inappropriate CHC prescription and increased stroke risk
• Overlooking additional risk factors: Even in migraine without aura, multiple risk factors compound stroke risk with CHCs
• Ignoring changing migraine patterns: Migraine characteristics can change over time, requiring reassessment of contraceptive choice
• Assuming all hormonal methods carry equal risk: Progestogen-only methods do not increase stroke risk and are safe alternatives