What contraceptive options are safe for women with migraines, especially those with aura?

Contraceptive Options for Women with Migraine

Women with migraine with aura should avoid combined hormonal contraceptives (pills, patches, rings) entirely and use progestin-only methods instead, as combined hormonal contraceptives dramatically increase stroke risk (RR 7.02) in this population. 1, 2

Contraindicated Methods

Combined hormonal contraceptives (CHCs) are absolutely contraindicated in women with migraine with aura due to multiplicative stroke risk. 2

• Women with migraine with aura who use oral contraceptives have a 7-fold increased risk of stroke (RR 7.02; 95% CI 1.51-32.68) compared to non-users 1
• The risk is particularly pronounced in women under age 45 (RR 3.65; 95% CI 2.21-6.04) 1
• Smoking further amplifies this risk dramatically (RR 9.03; 95% CI 4.22-19.34) 1
• Even low-dose estrogen formulations (≥30 μg ethinyl estradiol) carry increased stroke risk (OR 1.52; 95% CI 1.02-2.26) 3
• The absolute risk translates to approximately 4 additional intracranial hemorrhage events per 10,000 women per year 1

Recommended Safe Contraceptive Options

First-Line: Progestin-Only Pills (POPs)

Progestin-only pills are the preferred first-line contraceptive for women with migraine with aura, as they carry no increased stroke risk and may actually reduce migraine frequency. 2

• POPs (norethindrone) are classified as Category 1 (no restrictions) for women with migraine with aura by the CDC 1
• Desogestrel 75 μg has shown preliminary evidence of reducing migraine days, analgesic use, and symptom intensity in both migraine with and without aura 4
• Must be taken at the same time every day; backup contraception needed if taken >3 hours late 5
• Common side effect is irregular bleeding, which is not harmful but should be monitored 2, 5
• Avoid drospirenone-containing POPs in patients with hyperkalemia 2

Second-Line: Long-Acting Progestin Methods

Depot medroxyprogesterone acetate (DMPA) injections are safe alternatives that may reduce migraine frequency and cause amenorrhea with continued use. 2

• Classified as Category 2 (advantages generally outweigh risks) for migraine with aura 1
• Lasts 11-13 weeks, providing reliable contraception without daily adherence requirements 1
• May cause initial irregular bleeding before achieving amenorrhea 1

Levonorgestrel intrauterine device (LNG-IUD) is an excellent option that avoids systemic estrogen while managing menstrual irregularities. 2

Etonogestrel implant is safe for women with migraine with aura and provides 3 years of contraception. 2

Special Considerations for Migraine Without Aura

Women with migraine without aura have more contraceptive flexibility, though caution is still warranted:

• Age <35 years without additional risk factors: POPs classified as Category 2 (generally safe) 1
• Age ≥35 years: POPs classified as Category 3 (risks usually outweigh benefits); progestin-only methods strongly preferred 1
• Combined hormonal contraceptives may be considered in younger women without additional stroke risk factors (no smoking, hypertension, diabetes, hyperlipidemia, thrombophilia), though recent evidence suggests migraine without aura also increases stroke risk (OR 2.35; 95% CI 1.32-4.2) 3

Critical Risk Stratification

Absolute contraindications to combined hormonal contraceptives (use progestin-only methods only):

• Migraine with aura at any age 1, 2
• Migraine without aura + age ≥35 years 1
• Migraine + smoking 1
• Migraine + hypertension 1
• Migraine + diabetes, hyperlipidemia, or thrombophilia 1

Common Pitfalls to Avoid

• Do not assume low-dose estrogen formulations are safe in migraine with aura—even doses <30 μg carry increased stroke risk 3
• Do not dismiss migraine without aura as low-risk—recent evidence shows increased stroke risk (OR 2.35) even without aura 3
• Do not overlook the importance of timing with POPs—efficacy depends on strict daily adherence within a 3-hour window 5
• Do not prescribe combined hormonal contraceptives based solely on "low absolute risk"—the relative risk increase is substantial and preventable with safer alternatives 6, 7

Barrier Methods

Non-hormonal barrier methods (condoms, diaphragm, copper IUD) remain safe options for all women with migraine and should be discussed as alternatives or adjuncts to hormonal methods. 5