Is Yaz (drospirenone and ethinyl estradiol) safe for patients with migraines?

Yaz (Drospirenone/Ethinyl Estradiol) and Migraines

Yaz (drospirenone/ethinyl estradiol) is contraindicated in women with migraine with aura due to increased stroke risk, but may be considered for women with pure menstrual migraine without aura.

Safety Considerations for Yaz in Migraine Patients

Migraine with Aura

• Combined hormonal contraceptives like Yaz are absolutely contraindicated in women with migraine with aura regardless of any association with their menstrual cycle, due to an associated increase in risk of stroke 1
• The FDA label for drospirenone/ethinyl estradiol warns that the use of oral contraceptives is associated with increased risks of serious conditions including venous and arterial thrombotic and thromboembolic events such as stroke 2
• The risk of serious morbidity or mortality increases significantly in the presence of underlying risk factors 2

Migraine without Aura

• For women with pure menstrual migraine without aura, some may benefit from continuous use of combined hormonal contraceptives 1
• The 24/4 regimen of drospirenone/ethinyl estradiol (24 active pills, 4 placebo) has shown efficacy in reducing the intensity and duration of menstrual migraine without aura compared to the traditional 21/7 regimen 3
• Research indicates that drospirenone/ethinyl estradiol 24/4 regimen is recommended as the preferred treatment for patients suffering from pure menstrual migraine without aura 3

Contraindications and Precautions

• Yaz should not be used in patients with:

  • Migraine with aura (absolute contraindication) 1, 4
  • Conditions predisposing to hyperkalemia (renal insufficiency, hepatic dysfunction, adrenal insufficiency) 2
  • Women over 35 who smoke (significantly increased risk of cardiovascular side effects) 2

• Additional risk factors that require careful consideration:

  • Hypertension 2
  • Hyperlipidemia 2
  • Obesity 2
  • Diabetes 2

Alternative Treatments for Migraine Prevention

If Yaz is contraindicated, consider these evidence-based alternatives for migraine prevention:

First-line Preventive Medications

• Beta-blockers: atenolol (25-100 mg twice daily), bisoprolol (5-10 mg once daily), metoprolol (50-100 mg twice daily), propranolol (80-160 mg once or twice daily) 1, 4
• Angiotensin II receptor blockers: candesartan (16-32 mg daily) 1, 4
• Anticonvulsants: topiramate (50-100 mg daily) 1, 4

Second-line Preventive Medications

• Amitriptyline (10-100 mg at night) 1, 4
• Flunarizine (5-10 mg once daily) 1, 4
• Sodium valproate (600-1,500 mg once daily) - absolutely contraindicated in women of childbearing potential 1, 4

Third-line Preventive Medications

• CGRP monoclonal antibodies (erenumab, fremanezumab, eptinezumab) 1, 4
• OnabotulinumtoxinA (155-195 units to 31-39 sites every 12 weeks) 1

Monitoring and Follow-up

• Evaluate response to treatment within 2-3 months after initiation or change in treatment 1
• Use headache calendars to track attack frequency, severity, and medication use 1
• Monitor for signs of increased stroke risk or thromboembolic events in patients taking Yaz 2
• For patients on Yaz who have conditions or medications that may increase serum potassium, check serum potassium level during the first treatment cycle 2

Summary

For women with migraine, the decision to use Yaz should be based on the presence or absence of aura:

• Migraine with aura: Yaz is contraindicated due to increased stroke risk 1, 2
• Migraine without aura, particularly pure menstrual migraine: Yaz may be beneficial, with the 24/4 regimen showing better results than the 21/7 regimen 3

Always consider individual risk factors and monitor closely for adverse effects when prescribing Yaz to women with migraines 2.