Birth Control Options for Individuals with Migraine with Aura
Individuals with migraine with aura should avoid combined hormonal contraceptives and instead use progestin-only methods or non-hormonal contraception due to the significantly increased risk of ischemic stroke. 1
Contraindicated Birth Control Options
- Combined hormonal contraceptives (CHCs) containing estrogen are absolutely contraindicated in women with migraine with aura due to significantly increased risk of ischemic stroke 1, 2
- This contraindication applies to all estrogen-containing methods including pills, patches, and vaginal rings 3
- Migraine with aura is an independent risk factor for stroke, and this risk is further amplified when combined with estrogen-containing contraceptives 2, 1
- The American Heart Association/American Stroke Association explicitly recommends that individuals with migraine and aura who are taking oral contraceptives switch to another form of birth control 2
Recommended Birth Control Options
Progestin-Only Methods (First Choice)
- Progestin-only pills (POPs) are safe options that do not increase stroke risk 1, 4
- Progestin-only contraceptives have shown promise in potentially improving migraine symptoms in women with migraine with aura 5, 6
- Desogestrel 75 mcg/day has demonstrated effectiveness in reducing the number of migraine attacks, migraine days, and intensity of symptoms 5, 6
- Other progestin-only options include:
Non-Hormonal Methods (Safe Alternatives)
- Copper intrauterine device (IUD) - highly effective, long-acting, and reversible 1
- Barrier methods such as condoms, diaphragms, and cervical caps 1
- Permanent sterilization options (tubal ligation or vasectomy) if no future pregnancies are desired 1
Clinical Considerations
- When switching from combined hormonal contraceptives to progestin-only methods, patients should be informed about potential changes in bleeding patterns, which may include irregular spotting or amenorrhea 4, 5
- Progestin-only methods have been shown to be well-tolerated with less than 10% of women discontinuing due to side effects 6
- Regular follow-up is recommended to monitor for any changes in migraine pattern, frequency, or development of new neurological symptoms 1
- Additional stroke risk factors (smoking, hypertension, diabetes, hyperlipidemia) should be carefully assessed and managed 2, 7
Special Considerations
- Older studies suggesting that ultra-low-dose estrogen formulations might be safe for women with migraine with aura 8 are not supported by current guidelines, which maintain that all estrogen-containing contraceptives are contraindicated 1, 2
- For women over 35 years who smoke, the contraindication for combined hormonal contraceptives is even stronger due to compounded stroke risk 3
- Women with pure menstrual migraine without aura may have different contraceptive options, but this discussion specifically addresses migraine with aura 9
Summary Table of Contraceptive Options for Migraine with Aura
| Contraceptive Method | Stroke Risk | Recommendation |
|---|---|---|
| Progestin-only methods | None | Strongly recommended [1,4] |
| Non-hormonal methods | None | Safe alternatives [1] |
| Combined hormonal contraceptives | Increased | Contraindicated [2,1] |