Contraceptive Recommendations for Women with Migraines
Women with migraine with aura should avoid combined hormonal contraceptives containing estrogen due to increased stroke risk, and should instead use progestogen-only contraceptives, copper IUDs, or barrier methods. 1
Risk Stratification by Migraine Type
Migraine with Aura
- Estrogen-containing contraceptives are contraindicated due to substantially elevated ischemic stroke risk (OR 2.08 to 16.9 for ischemic stroke) 1
- The American Heart Association/American Stroke Association explicitly recommends avoiding oral contraceptive agents with exogenous estrogen in women with migraine with aura, particularly when combined with smoking 1
- This restriction applies even without prior stroke history, as the combination of migraine with aura and estrogen-containing contraceptives creates unacceptable vascular risk 1
Migraine without Aura
- Combined hormonal contraceptives may be used only if no additional stroke risk factors are present 2
- Additional risk factors that contraindicate estrogen use include: smoking, hypertension, diabetes, hyperlipidemia, thrombophilia, and age over 35 years 3, 4
- If any of these risk factors exist, progestogen-only methods should be used instead 2
Recommended Contraceptive Options
First-Line: Progestogen-Only Methods
- Desogestrel 75 mcg daily is the best-studied progestogen-only pill, showing modest reduction in migraine attacks, migraine days, attack intensity, and analgesic use 5
- Progestogen-only contraceptives do not increase risk of venous thromboembolism or ischemic stroke 3
- These methods may actually improve migraine by maintaining stable estrogen levels and inhibiting ovulation 3, 6
- Other progestogen-only options include: other progestin-only pills, depot medroxyprogesterone acetate, etonogestrel implant, and levonorgestrel IUD 2
Alternative: Non-Hormonal Methods
- Copper IUD can be safely used in all women with migraine regardless of aura status 2
- Barrier methods carry no contraindications for migraine patients
Special Consideration: Menstrual Migraine
- For women with confirmed menstrual-related migraine (affecting 50% of women with migraine), if acute treatment fails, use perimenstrual preventive treatment with long-acting NSAIDs or triptans for 5 days, beginning 2 days before expected menstruation 7
- Extended-cycle combined hormonal contraceptives or shortened hormone-free intervals may help by minimizing estrogen fluctuations, but only in women with migraine without aura and no additional risk factors 6
Critical Caveats
- If a woman on combined hormonal contraceptives experiences migraine aura for the first time, discontinue the contraceptive immediately 4
- Clear worsening of preexistent aura also mandates discontinuation 4
- Laboratory screening for hereditary thrombophilia should be considered before prescribing any estrogen-containing contraceptive in migraine patients, as all combined hormonal contraceptives increase venous thrombosis risk 4
- The quality of evidence linking estrogen-containing contraceptives to stroke in migraine is acknowledged as low, but the potential severity of outcomes justifies cautious prescribing 1