What are the recommended birth control options for a female patient of childbearing age with a history of migraines with aura?

Migraine with Aura Birth Control Recommendations

Women with migraine with aura must avoid all combined hormonal contraceptives (pills, patches, rings) and should use progestin-only methods instead, as combined hormonal contraceptives increase stroke risk 7-fold in this population. 1

Absolutely Contraindicated Methods

Combined hormonal contraceptives are completely prohibited in migraine with aura due to multiplicative stroke risk:

• Combined oral contraceptives, patches, and vaginal rings are contraindicated regardless of age, as they increase ischemic stroke risk 7-fold (RR 7.02; 95% CI 1.51-32.68) compared to non-users 1
• The risk is particularly severe in women under age 45 (RR 3.65; 95% CI 2.21-6.04) 1
• Smoking amplifies this risk catastrophically (RR 9.03; 95% CI 4.22-19.34), making tobacco use an absolute contraindication if any hormonal contraception is considered 1
• The absolute risk translates to approximately 4 additional intracranial hemorrhage events per 10,000 women per year 1
• The American Heart Association/American Stroke Association explicitly recommends against estrogen-containing contraceptives in individuals with migraine with aura 2

First-Line Recommended Option: Progestin-Only Pills

Progestin-only pills (POPs) are the preferred first-line contraceptive for migraine with aura, classified as Category 1 (no restrictions) by the CDC:

• Norethindrone-containing POPs carry no increased stroke risk and may actually reduce migraine frequency 1
• These pills do not alter coagulation or exacerbate migraine like combined hormonal contraceptives 3
• The most common side effect is irregular bleeding, which is not harmful but requires patient counseling 1
• Avoid drospirenone-containing POPs only in patients with hyperkalemia 1
• Research demonstrates that desogestrel 75 mcg/day POP significantly reduces migraine attacks, migraine days, intensity, duration, and analgesic use while improving quality of life 4

Second-Line Safe Alternatives

Long-acting progestin methods provide excellent alternatives when daily pill adherence is challenging:

Depot Medroxyprogesterone Acetate (DMPA) Injections

• Classified as Category 2 (advantages generally outweigh risks) for migraine with aura 1
• Lasts 11-13 weeks, eliminating daily adherence requirements 1
• May reduce migraine frequency and cause amenorrhea with continued use 1
• Initial irregular bleeding typically resolves before achieving amenorrhea 1

Levonorgestrel Intrauterine Device (LNG-IUD)

• Excellent option that avoids systemic estrogen while managing menstrual irregularities 1
• Provides 3-5 years of contraception depending on formulation 1

Etonogestrel Implant

• Safe for women with migraine with aura and provides 3 years of contraception 1
• Single-rod subdermal implant with minimal systemic progestin exposure 5

Non-Hormonal Option

Copper intrauterine device (IUD) is completely safe:

• Carries zero stroke risk as it contains no hormones 6
• Provides 10 years of highly effective contraception 6
• May worsen dysmenorrhea and menstrual bleeding, which could be problematic if menstrual migraine is present 6

Critical Risk Factor Assessment

Before prescribing any contraception, evaluate and eliminate additional stroke risk factors:

• Tobacco use: Absolutely prohibit smoking, as it creates catastrophic stroke risk when combined with migraine with aura 1
• Hypertension: Screen for and aggressively manage elevated blood pressure 1
• Thrombophilia: Evaluate for inherited clotting disorders before initiating any hormonal method 7
• Diabetes and hyperlipidemia: Screen for metabolic risk factors that compound stroke risk 1
• Age over 35: Increases baseline stroke risk, making progestin-only methods even more critical 1

Special Clinical Scenarios

If Patient Previously Used Combined Hormonal Contraceptives

• Switch immediately to progestin-only methods as it is reasonable to advise individuals with migraine and prior stroke risk who are taking oral contraceptives to change to another form of birth control 3

If Migraine Frequency is High (>Weekly)

• High migraine frequency with aura further amplifies ischemic stroke risk (HR 4.25; 95% CI 1.36-13.29) 2
• Consider adding migraine prophylaxis (propranolol 80-160 mg daily or topiramate 50-100 mg daily) alongside progestin-only contraception 8

If Patient Has Migraine Without Aura

• Age <35 years without additional risk factors: Combined hormonal contraceptives classified as Category 2 (generally safe) 1
• Age ≥35 years: Combined hormonal contraceptives classified as Category 3 (risks usually outweigh benefits); strongly prefer progestin-only methods 1

Common Pitfalls to Avoid

• Do not assume all migraines are the same: Migraine with aura carries dramatically higher stroke risk than migraine without aura when combined with estrogen 3
• Do not prescribe "low-dose" combined hormonal contraceptives thinking they are safer: Even modern low-dose formulations remain contraindicated in migraine with aura 9
• Do not overlook smoking status: This single factor can increase stroke risk 9-fold when combined with migraine and estrogen 1
• Do not dismiss irregular bleeding as a contraindication: Irregular bleeding with progestin-only methods is not harmful and typically improves with continued use 1