Contraceptive Implant Use with Severe Migraines
The contraceptive implant (progestin-only) can be safely used in women with severe migraines, including migraine with aura, as it does not contain estrogen and therefore does not carry the increased stroke risk associated with combined hormonal contraceptives.
Key Distinction: Combined vs. Progestin-Only Methods
Combined hormonal contraceptives (containing estrogen) are absolutely contraindicated in women with migraine with aura due to an associated increase in the risk of ischemic stroke 1
The stroke risk concern specifically relates to estrogen-containing contraceptives, which when combined with migraine with aura, creates a two- to fourfold increased risk of stroke compared to nonuse 2, 3
Progestin-only methods, including the contraceptive implant, do not carry this same stroke risk and represent safe alternatives for women with any type of migraine 4
Evidence Supporting Progestin-Only Contraception Safety
The increased stroke risk in migraineurs is specifically associated with combined hormonal contraceptives containing ethinylestradiol, and this risk is dose-dependent 4
Women with migraine with aura have a twofold increased risk of ischemic stroke independent of contraceptive use, but combined hormonal contraceptives magnify this risk additively 2, 5
No evidence suggests that progestin-only methods increase stroke risk in women with migraine, making them the preferred contraceptive choice for this population 4, 3
Clinical Recommendations for Contraceptive Selection
For women with migraine without aura: Combined hormonal contraceptives may be used, though progestin-only methods remain safer alternatives 1, 4
For women with migraine with aura: Switch from any combined hormonal contraceptive to a progestin-only method such as the implant, progestin-only pills, injectable progestins, or progestin IUDs 1
For women with prior ischemic stroke and migraine: It is reasonable to advise switching from oral contraceptives to another form of birth control, with progestin-only methods being the safest hormonal option 1
Additional Risk Factors Requiring Consideration
The presence of additional stroke risk factors (smoking, hypertension, age >35 years, complex or prolonged aura) further elevates risk when combined hormonal contraceptives are used in migraineurs 5
Women with hemiplegic migraine, basilar migraine, or known vascular risk factors should avoid combined hormonal contraceptives entirely 1
Common Pitfall to Avoid
Do not deny all hormonal contraception to women with severe migraines—this unnecessarily limits access to highly effective contraception when progestin-only methods are safe and appropriate 6, 4
The absolute risk of ischemic stroke remains very low in healthy, nonsmoking young women even with migraine, but the key is avoiding estrogen-containing methods in those with aura 2, 4