What progesterone-only oral contraceptive (POC) is recommended for a 20-year-old patient with migraines with aura?

Progesterone-Only Oral Contraceptives for Migraines with Aura

For a 20-year-old patient with migraines with aura, a progestin-only pill containing norethindrone or drospirenone is strongly recommended as the safest hormonal contraceptive option. 1

Contraindication of Combined Hormonal Contraceptives

• Combined hormonal contraceptives (CHCs) containing estrogen are contraindicated in women with migraine with aura due to significantly increased risk of ischemic stroke 1, 2
• Migraine with aura is an independent risk factor for stroke, and this risk is further amplified when combined with estrogen-containing contraceptives 1
• The American Heart Association/American Stroke Association explicitly recommends against using estrogen-containing contraceptives in individuals with migraine with aura 1

Recommended Contraceptive Options

First-Line Option: Progestin-Only Pills

• Progestin-only pills (POPs) containing norethindrone or drospirenone are safe options that do not increase stroke risk 1
• According to the 2024 AHA/ASA guidelines, progestin-only contraception carries no increased stroke risk, unlike estrogen-containing methods 1
• POPs have demonstrated effectiveness with contraceptive success rates of <90% 1

Clinical Evidence Supporting POPs

• A prospective diary-based study showed that desogestrel-containing progestin-only pills significantly reduced the number of migraine attacks in women with migraine with aura 3
• The same study also demonstrated a beneficial effect on the duration of visual aura and total duration of neurological symptoms 3

Alternative Non-Hormonal Options

• Non-hormonal contraceptive methods that carry no stroke risk include:
  • Barrier methods (condoms, diaphragm) 1
  • Copper intrauterine device (IUD) 1
  • Surgical sterilization (if permanent contraception is desired) 1

Important Considerations and Monitoring

• Progestin-only methods may cause irregular bleeding patterns, which should be discussed with the patient 1
• Regular follow-up is recommended to monitor:
  • Changes in migraine pattern or frequency 2
  • Development of any new neurological symptoms 1
  • Tolerability of the contraceptive method 3

Common Pitfalls to Avoid

• Prescribing combined hormonal contraceptives (even low-dose formulations) despite some recent studies suggesting lower risk 4, 5
  • Current guidelines still maintain that CHCs are contraindicated in migraine with aura 1, 2
• Failing to recognize that even newer, lower-dose estrogen formulations still carry some increased stroke risk in this population 1
• Not considering that additional risk factors (smoking, hypertension) can further increase stroke risk 1, 6

Summary of Contraceptive Options for Migraine with Aura

Contraceptive Method	Stroke Risk	Recommendation
Progestin-only pills	None	Strongly recommended [1]
Progestin IUD	None	Strongly recommended [1]
Progestin implant	None	Strongly recommended [1]
Combined hormonal contraceptives	Increased	Contraindicated [1,2]
Non-hormonal methods	None	Safe alternatives [1]