Contraceptive Options for Women with Migraine Without Aura
Women with migraine without aura can safely use any contraceptive method, including combined hormonal contraceptives, as they do not have an increased risk of stroke compared to women with migraine with aura.
Safe Contraceptive Options
Combined Hormonal Contraceptives (CHCs)
- Combined oral contraceptives (COCs), vaginal rings, and patches are all appropriate options 1
- Low-dose formulations (containing ethinyl estradiol 35 μg or less) are preferred 1
- Extended or continuous regimens (24/4 rather than 21/7) may be beneficial for reducing menstrual migraine severity 2
Progestin-Only Methods
- All progestin-only methods are safe and appropriate:
- Progestin-only pills
- Levonorgestrel intrauterine device (IUD) - particularly beneficial for menstrual migraine 3
- Etonogestrel implant (Nexplanon)
- Depot medroxyprogesterone acetate injections
Non-Hormonal Methods
- Copper IUD
- Barrier methods (condoms, diaphragms, caps)
- Fertility awareness methods
Benefits of Hormonal Contraception for Migraine Without Aura
- Hormonal contraceptives, particularly extended regimens, can help manage menstrual migraine by stabilizing estrogen levels 4
- The 24/4 COC regimen (24 active pills + 4 placebo pills) has been shown to significantly reduce the intensity and duration of menstrual migraine compared to the traditional 21/7 regimen 2
- The levonorgestrel IUD is recommended by the American College of Obstetricians and Gynecologists as a preferred continuous progestogen option for menstrual migraine prevention 3
Important Monitoring Considerations
Regular follow-up every 6-12 months to monitor:
- Changes in migraine pattern
- Development of aura symptoms (which would necessitate discontinuation of CHCs)
- Cardiovascular risk factors
- Treatment effectiveness using headache calendars 3
Blood pressure should be monitored at baseline and during follow-up visits 1
Key Distinctions and Warnings
- Important distinction: Migraine WITH aura is a contraindication to combined hormonal contraceptives due to significantly increased stroke risk 1, 3
- Monitor for development of aura symptoms, which would require discontinuation of CHCs
- Additional risk factors that would contraindicate CHC use include:
- Age ≥35 years and smoking
- Uncontrolled hypertension
- Thrombophilia or history of thromboembolism
- Complicated valvular heart disease 1
Algorithm for Contraceptive Selection in Migraine Without Aura
First-line options:
- Low-dose combined hormonal contraceptives (≤35 μg ethinyl estradiol) if no other contraindications exist
- Consider extended or continuous regimens (24/4) for better migraine control
If menstrual migraine is severe or patient prefers non-estrogen methods:
- Levonorgestrel IUD
- Other progestin-only methods
If hormonal methods are contraindicated or not desired:
- Copper IUD
- Barrier methods
Immediately discontinue CHCs and switch to non-estrogen methods if:
- Aura symptoms develop
- New cardiovascular risk factors emerge
- Migraine frequency or severity significantly worsens
By following these guidelines, women with migraine without aura can safely use contraceptive methods that may also help manage their migraine symptoms.