Emergency Contraception and Migraine History
False - Emergency contraception is NOT contraindicated in patients with a history of migraine, including migraine with aura.
Emergency contraception (levonorgestrel or ulipristal acetate) is fundamentally different from combined hormonal contraceptives and does not carry the same stroke risk concerns that apply to ongoing estrogen-containing contraceptive methods.
Key Distinction: Emergency vs. Combined Hormonal Contraception
The contraindication in migraine specifically applies to combined hormonal contraceptives containing estrogen used for ongoing contraception, not to emergency contraception 1, 2, 3.
Why Combined Hormonal Contraceptives Are Contraindicated in Migraine with Aura:
- Combined hormonal contraceptives (CHCs) containing estrogen are absolutely contraindicated in women with migraine with aura due to significantly increased ischemic stroke risk 2, 3, 4
- The American Heart Association/American Stroke Association explicitly recommends against using estrogen-containing contraceptives in individuals with migraine with aura 2
- Migraine with aura is an independent stroke risk factor that is further amplified when combined with estrogen-containing contraceptives 2, 4
Why Emergency Contraception Is Safe:
- Emergency contraception consists of progestin-only formulations (levonorgestrel) or selective progesterone receptor modulators (ulipristal acetate) that do not contain estrogen 1, 2
- Progestin-only contraception carries no increased stroke risk, unlike estrogen-containing methods 1, 2, 3
- Emergency contraception is a single-use, short-duration intervention rather than continuous hormonal exposure 5
Clinical Algorithm for Contraception in Migraine Patients:
For Migraine WITHOUT Aura:
- Combined hormonal contraceptives with <50 μg estrogen can be used if no other stroke risk factors present (age <35, no tobacco use, normal blood pressure, no thrombophilia) 1, 4, 6
- Lower estrogen doses (20 μg ethinyl estradiol) minimize stroke risk 1
- Emergency contraception is safe 1, 2
For Migraine WITH Aura:
- All combined hormonal contraceptives containing estrogen must be avoided 2, 3, 4
- Progestin-only pills, progestin IUD, or progestin implant are strongly recommended alternatives 2, 3
- Emergency contraception (progestin-only) is safe and appropriate 2, 3
Common Pitfall to Avoid:
Do not confuse the contraindication for ongoing combined hormonal contraceptives with emergency contraception. Emergency contraception is progestin-only and does not carry the stroke risk associated with estrogen-containing methods 1, 2, 3. Denying emergency contraception to a patient with migraine history would be inappropriate and potentially harmful, as it would increase risk of unintended pregnancy without any medical justification 2, 3.