Hormonal Contraceptives for Premenstrual Migraines
Yes, hormonal contraceptives can help alleviate premenstrual migraines, but the approach depends critically on whether you have migraine with or without aura, and the strategy must focus on eliminating estrogen withdrawal rather than using standard cyclic regimens.
Key Distinction: Migraine Type Determines Safety
- Migraine without aura: Hormonal contraceptives are safe and can be therapeutic 1
- Migraine with aura: Combined hormonal contraceptives (CHCs) are contraindicated due to stroke risk; progestogen-only pills are the safe alternative 2, 3
Understanding the Mechanism
The migraines occurring before your period are triggered by the drop in estrogen levels 4. Approximately 50% of women with migraine experience increased attacks during menstruation, though only 8% have exclusively menstrual-related attacks 1. Standard cyclic birth control pills actually worsen this problem because they create a 7-day hormone-free interval that mimics the natural estrogen withdrawal 2, 5.
Recommended Hormonal Strategies (For Migraine Without Aura)
The goal is to maintain stable estrogen levels and eliminate the hormone-free interval:
Primary Approach: Extended or Continuous Regimens
- Use combined hormonal contraceptives continuously without the traditional 7-day break 2, 4
- This prevents the estrogen withdrawal that triggers your migraines 4
- Can use pills, patches, or vaginal rings in extended cycles 4
Alternative Approaches if Continuous Use Isn't Feasible:
Shortened hormone-free interval: Reduce the pill-free week to less than 7 days (ideally 4 days or fewer) 2, 4
Estrogen supplementation during the hormone-free week:
- Add low-dose estrogen (such as 0.9 mg conjugated equine estrogens or 1.5 mg transcutaneous estradiol) during days 22-28 of the cycle 1, 5
- One study showed 77.9% reduction in headache days using 20 μg ethinyl estradiol pills supplemented with conjugated estrogens during the placebo week 5
- Limiting the estrogen decline to less than 20 μg equivalent prevents menstrual-associated migraine 5
Ultra-low-dose formulations: Pills containing less than 20 μg ethinyl estradiol in continuous regimens may reduce migraine frequency 3
For Migraine With Aura: Progestogen-Only Options
If you have migraine with aura, you must avoid combined hormonal contraceptives entirely 2, 3:
- Progestogen-only pills (POPs) are safe and effective 2
- Recent evidence suggests POPs can reduce both migraine attack frequency and aura symptom duration 2
- Other progestogen-only methods (implants, injections, IUDs) are also safe alternatives
Clinical Pitfalls to Avoid
Don't use standard 21/7 cyclic regimens if preventing menstrual migraines is your goal—this perpetuates the estrogen withdrawal trigger 2, 5
Initial worsening is common: Headaches may worsen in the first few months of CHC use but generally improve thereafter 2
Timing matters for supplementation: If using estrogen supplementation during the hormone-free interval, migraine typically starts on days 1-5 of the hormone-free period or days -1 to 4 relative to bleeding onset 6
If Hormonal Contraceptives Aren't Sufficient
The American Academy of Neurology and European Headache Federation recommend perimenstrual preventive treatment if optimized hormonal strategies don't suffice 1:
- Start a long-acting NSAID or triptan 2 days before expected menstruation
- Continue for 5 days total 1
- This is specifically for confirmed menstrual migraine when hormonal manipulation alone is inadequate
Bottom Line Algorithm
- Confirm migraine type (with or without aura)
- If migraine without aura: Use continuous or extended-cycle CHCs as first-line approach 2, 4
- If migraine with aura: Use progestogen-only contraceptives only 2
- If breakthrough migraines persist: Add perimenstrual NSAID or triptan prophylaxis 1
- Monitor for 3-4 months before declaring treatment failure, as initial worsening is common 2