Can Mirena (levonorgestrel) reduce menstrual migraines?

Mirena (Levonorgestrel IUD) for Menstrual Migraine

Yes, Mirena can effectively reduce menstrual migraines by stabilizing hormone levels and often reducing or eliminating menstrual bleeding, which removes the hormonal trigger for these headaches.

Mechanism of Action for Migraine Prevention

• Mirena releases levonorgestrel locally in the uterus, providing a progestin-only contraceptive option
• Works by:
  • Stabilizing hormone levels, particularly preventing estrogen withdrawal
  • Often reducing or eliminating menstrual bleeding (amenorrhea in many users)
  • Avoiding the estrogen fluctuations that typically trigger menstrual migraines

Evidence Supporting Mirena for Menstrual Migraine

Progestin-only contraceptives like Mirena are recommended for migraine management because:

1. Safety profile: Progestin-only methods are considered safe for individuals with migraine, including those with aura, as they don't increase stroke risk 1

2. Hormone stabilization: Menstrual migraines are triggered by estrogen "withdrawal" during the late luteal and menstrual phases 2

3. Therapeutic approach: For menstrual migraine, maintaining a stable estrogen environment can benefit estrogen-withdrawal migraine 3

4. Preferred delivery system: Continuous progestogens, as provided by the levonorgestrel intrauterine system (Mirena), are preferred over cyclical progestogens which can adversely affect migraine 3

Treatment Algorithm for Menstrual Migraine

First-line options:

1. Acute treatment: NSAIDs (acetylsalicylic acid, ibuprofen, diclofenac) or triptans for breakthrough headaches 4

For inadequate response to acute treatments:

1. Short-term prevention (for pure menstrual migraine):
   • Long-acting NSAIDs or triptans (frovatriptan preferred) for 5 days starting 2 days before expected menstruation 4, 5

For severe or frequent menstrual migraines:

1. Hormonal prevention options:
   • Levonorgestrel IUD (Mirena) - preferred continuous progestogen option 3
   • Other progestin-only methods (implant, injections, pills) 1

For those who cannot use hormonal methods:

1. Standard migraine preventives:
   • Beta-blockers (propranolol 80-160mg daily) 4
   • Amitriptyline (10-100mg at night) 4
   • Topiramate (50-100mg daily) 4, 1

Important Considerations

• Safety advantage: Mirena is safer than combined hormonal contraceptives for women with migraine with aura, who have a 7-fold increased risk of ischemic stroke with estrogen-containing contraceptives 1

• Monitoring: Regular follow-up is recommended to assess migraine pattern changes and treatment effectiveness 1

• Potential limitations: Some women may experience hormonal side effects with Mirena, though these are typically less pronounced than with other hormonal methods due to the localized hormone delivery

• Caution: If Mirena does not adequately control menstrual bleeding, the hormonal fluctuations may still trigger migraines in some women

When to Consider Alternative Approaches

• If Mirena is not tolerated or contraindicated
• If breakthrough migraines persist despite Mirena
• If other migraine triggers beyond menstruation are significant

For women with pure menstrual migraine who don't respond to Mirena, consider adding perimenstrual preventive treatment with frovatriptan, naproxen, or other recommended options 6, 5.