Is it safe to use Yaz (drospirenone and ethinyl estradiol) in patients with a history of migraines?

Safety of Yaz in Patients with History of Migraines

Women with migraine with aura should avoid combined hormonal contraceptives like Yaz (drospirenone and ethinyl estradiol) due to increased stroke risk. 1

Understanding the Risk

Yaz is a combined oral contraceptive (COC) containing drospirenone (a progestin) and ethinyl estradiol (an estrogen). When considering its use in patients with migraines, the key distinction is whether the patient has migraines with aura or without aura:

• Migraines with aura: These are absolutely contraindicated for Yaz or any estrogen-containing contraceptive due to significantly increased stroke risk 1
• Migraines without aura: May be considered with caution, but other contraceptive options should be prioritized

Clinical Decision Algorithm

1. Determine migraine type:

   • Does the patient experience aura symptoms (visual disturbances, sensory symptoms, speech disturbances) before or during headaches?
   • If YES → Absolutely avoid Yaz and all estrogen-containing contraceptives
   • If NO → Proceed with caution to step 2

2. Assess additional risk factors for thrombosis:

   • Age ≥35 years
   • Smoking
   • Hypertension
   • Family history of thrombotic events
   • Obesity
   • If ANY present → Consider non-estrogen contraceptive options

3. For patients with migraines without aura and no additional risk factors:

   • Discuss potential benefits of Yaz (contraception, cycle control, potential improvement in premenstrual symptoms) 2, 3
   • Explain risks, including rare but serious risks of thrombosis 4
   • Monitor closely for any change in migraine pattern or frequency

Important Considerations

• While Yaz has been shown to be effective for contraception and treatment of premenstrual symptoms 2, 3, its safety profile in migraine patients must be carefully considered
• Drospirenone has antimineralocorticoid and antiandrogenic properties that differentiate it from other progestins 2, but these properties do not mitigate the stroke risk associated with estrogen in patients with migraine with aura
• Common side effects of Yaz include nausea, intermenstrual bleeding, and breast pain 3

Alternative Contraceptive Options for Migraine Patients

For patients with migraine with aura or those with multiple risk factors:

• Progestin-only pills
• Intrauterine devices (hormonal or non-hormonal)
• Implants
• Barrier methods

Monitoring Recommendations

If Yaz is prescribed to a patient with migraines without aura (after careful consideration):

• Instruct patient to report immediately any:
  • Change in headache frequency, severity, or pattern
  • Development of aura symptoms
  • Symptoms of thrombosis (leg pain/swelling, chest pain, shortness of breath, severe headache, visual changes)
• Schedule follow-up within 3 months to assess tolerance and migraine impact

Pitfalls to Avoid

• Never prescribe Yaz or any estrogen-containing contraceptive to patients with migraine with aura - this is a dangerous combination that significantly increases stroke risk 1
• Don't assume that the unique properties of drospirenone make Yaz safer than other COCs for migraine patients
• Don't overlook changes in migraine pattern after starting Yaz, as this could indicate increased risk
• Don't continue Yaz if a patient develops aura symptoms while on the medication

The evidence clearly indicates that the safest approach is to avoid estrogen-containing contraceptives like Yaz in patients with migraine with aura, and to exercise caution even in those with migraine without aura.