Can I use Nexplanon (etonogestrel) with migraines with aura?

Nexplanon Use in Patients with Migraine with Aura

Nexplanon (etonogestrel implant) is a safe contraceptive option for individuals with migraine with aura, as progestin-only contraceptives do not increase stroke risk in this population. 1

Safety of Progestin-Only Methods vs. Combined Hormonal Contraceptives

Progestin-Only Methods (Including Nexplanon)

• Progestin-only contraceptives, including the etonogestrel implant (Nexplanon), are considered safe for women with migraine with aura 1
• These methods do not increase stroke risk in women with migraine with aura 1
• The American Heart Association/American Stroke Association 2024 guidelines specifically recommend progestin-only contraception for individuals with migraine with aura 2, 1

Combined Hormonal Contraceptives (CHCs)

• CHCs are contraindicated in women with migraine with aura due to significantly increased stroke risk 1
• Meta-analyses show that oral contraceptive use in women with migraine with aura increases ischemic stroke risk by 7-fold (RR 7.02; 95% CI, 1.51-32.68) 1
• The risk is particularly elevated when migraine with aura is combined with:
  • Age ≥35 years (RR 3.65; 95% CI, 2.21-6.04) 1
  • Smoking (RR 9.03; 95% CI, 4.22-19.34) 1

Clinical Decision-Making Framework

Risk Assessment

1. Confirm diagnosis of migraine with aura

   • Women with migraine with aura have an independent increased risk of ischemic stroke (RR 2.16; 95% CI, 1.53-3.03) compared to those without aura 1

2. Evaluate additional stroke risk factors:

   • Age >35 years
   • Tobacco use
   • Hypertension
   • Other cardiovascular risk factors

Contraceptive Options for Women with Migraine with Aura

1. First-line options (recommended):

   • Progestin-only methods including:
     • Etonogestrel implant (Nexplanon)
     • Levonorgestrel intrauterine device
     • Depot medroxyprogesterone acetate injections
     • Progestin-only pills

2. Alternative options:

   • Non-hormonal methods:
     • Copper IUD
     • Barrier methods
     • Fertility awareness methods

Benefits of Nexplanon for Women with Migraine

• Long-acting (effective for up to 3 years)
• Highly effective (>99%)
• No need for daily compliance
• Some evidence suggests progestin-only methods may have beneficial effects on migraine symptoms 3

Follow-Up and Monitoring

• Regular follow-up every 2-3 months initially, then every 6-12 months 1
• Monitor for:
  • Changes in migraine pattern
  • Development of new aura symptoms
  • Cardiovascular risk factors
  • Treatment effectiveness using headache calendars

Common Pitfalls to Avoid

1. Misclassification of migraine type: Ensure proper diagnosis of migraine with aura versus migraine without aura, as this significantly impacts contraceptive safety recommendations

2. Overlooking newer evidence: While older studies showed significant risks with hormonal contraceptives, these were based on higher-dose estrogen formulations from the 1960s-1970s 4

3. Ignoring additional risk factors: The risk of stroke is compounded when multiple risk factors are present (smoking, age >35, hypertension) 1

4. Failure to provide effective contraception: Avoiding unintended pregnancy is also important for women with migraine with aura, as pregnancy itself carries stroke risk

In conclusion, Nexplanon is an appropriate and safe contraceptive choice for individuals with migraine with aura, as it provides highly effective contraception without the increased stroke risk associated with estrogen-containing methods.