What are the recommended contraceptive options for a woman with migraines and a history of Pelvic Inflammatory Disease (PID)?

Contraceptive Options for Women with Migraines and History of PID

For women with migraines and a history of pelvic inflammatory disease (PID), progestin-only contraceptive methods are the safest and most effective options, particularly the levonorgestrel intrauterine device (LNG-IUD) or progestin-only pills.

Migraine Considerations

Migraine with Aura

• Combined hormonal contraceptives (CHCs) are contraindicated in women with migraine with aura due to significantly increased stroke risk 1
• Risk of ischemic stroke is 2.5 times higher in women with migraine with aura compared to those without aura 1
• This risk is further amplified when combined with:
  • Age <45 years (RR 3.65)
  • Smoking (RR 9.03)
  • Oral contraceptive use (RR 7.02) 1

Migraine without Aura

• Women with migraine without aura have a lower stroke risk (RR 1.23) compared to those with aura 1
• While some recent research suggests modern low-dose CHCs may have less risk 2, 3, current guidelines still recommend avoiding CHCs in women with any type of migraine, particularly those with additional risk factors

PID Considerations

• History of PID does not preclude most contraceptive methods 4
• IUD insertion carries a slightly increased risk of PID in the first 20 days after insertion, but then returns to baseline risk 5
• For women with a history of PID who are not currently experiencing active infection, IUDs can be safely used 6
• If PID occurs in a woman with an existing IUD:
  • The IUD does not need to be removed immediately
  • Treat with appropriate antibiotics per guidelines
  • Reassess in 24-48 hours; if no improvement, consider IUD removal 1

Recommended Contraceptive Options

First-Line Options:

1. Levonorgestrel IUD (LNG-IUD)

   • Safe for women with any type of migraine 1
   • Highly effective (>99%)
   • Reduces menstrual bleeding, which may help with menstrual-related migraines
   • Can be used safely in women with history of PID (if not currently active) 6
   • Provides 3-8 years of contraception depending on the specific device

2. Progestin-only pills

   • Safe for women with any type of migraine
   • No increased stroke risk
   • Must be taken at the same time daily for maximum effectiveness

3. Progestin implant

   • Safe for women with any type of migraine
   • Highly effective (>99%)
   • Provides 3-5 years of contraception

4. Copper IUD

   • Safe for women with any type of migraine 1
   • Highly effective (>99%)
   • Non-hormonal option
   • May increase menstrual bleeding, which could potentially trigger menstrual migraines
   • Can be used safely in women with history of PID (if not currently active) 6
   • Provides up to 10 years of contraception

Second-Line Options:

1. Barrier methods (condoms, diaphragms with spermicide)
   • Safe for all women with migraine
   • Added benefit of STI protection, which may help prevent recurrent PID 4
   • Lower effectiveness rates with typical use
   • Require consistent and correct use

Contraceptive Methods to Avoid

• Combined hormonal contraceptives (pills, patch, ring)
  • Contraindicated in women with migraine with aura due to increased stroke risk 1
  • Use caution even in women with migraine without aura, especially if they have additional stroke risk factors

Monitoring and Follow-up

• For women choosing an IUD:

  • Monitor for signs of infection in the first month after insertion
  • Teach the patient to recognize symptoms of PID that would require prompt medical attention
  • Regular follow-up to ensure proper IUD placement

• For women with migraines:

  • Monitor migraine frequency and characteristics
  • Any development of aura symptoms should prompt reevaluation of contraceptive method

Special Considerations

• If emergency contraception is needed, copper IUD is preferred over hormonal options for women with migraine with aura 1
• Women with both migraines and PID history should be counseled about consistent condom use to prevent STIs and subsequent PID recurrence, regardless of which contraceptive method they choose

By carefully selecting appropriate contraceptive methods based on migraine status and PID history, healthcare providers can help women effectively prevent pregnancy while minimizing health risks.