What birth control options are available for a female patient of reproductive age with a history of headaches that do not exacerbate headaches?

Birth Control Options That Do Not Exacerbate Headaches

For women with a history of headaches, progestin-only methods (levonorgestrel IUD, progestin implant, or progestin-only pills) and non-hormonal copper IUDs are the safest contraceptive choices that will not worsen headaches, while combined estrogen-containing contraceptives should be avoided. 1

Critical First Step: Assess for Migraine with Aura

The most important clinical distinction is whether you experience migraine with aura (visual disturbances, numbness, speech changes before headache) versus headaches without aura, as this determines absolute contraindications 2:

• If migraine WITH aura is present: Combined hormonal contraceptives (pills, patches, rings containing estrogen) are absolutely contraindicated due to 2-4 times increased stroke risk 2
• If headaches WITHOUT aura: More contraceptive options are available, though estrogen-containing methods may still worsen headache frequency 1, 3

Recommended Contraceptive Options for Women with Headaches

First-Line: Long-Acting Reversible Contraceptives (LARCs)

Levonorgestrel IUD (Mirena, Skyla) is the optimal choice 1, 4:

• Highest efficacy (<1% pregnancy rate annually) 4, 5, 6
• Progestin-only formulation does not increase headache risk 1
• Safe for women with any headache type, including migraine with aura 1
• Additional benefit: reduces menstrual bleeding by 35% amenorrhea rate after 2 years 5, 6
• Potential side effects include headaches in some users (though not worsening pre-existing headaches), breast tenderness, and ovarian cysts 5, 6

Copper IUD (Paragard) is an excellent hormone-free alternative 1, 4:

• Completely non-hormonal, eliminating any hormonal headache triggers 5, 7, 8
• Equivalent contraceptive efficacy (<1% failure rate) 4, 5, 8
• Safe for all women with headaches, including migraine with aura 1
• Main drawback: increased menstrual bleeding and cramping 5, 6, 8
• After 5 years, approximately 50% of women continue use 8

Progestin implant (Nexplanon) 1:

• Highly effective progestin-only method safe for headache sufferers 1
• Does not contain estrogen, avoiding headache exacerbation 1

Second-Line: Progestin-Only Pills

Progestin-only pills (mini-pills) are acceptable but less preferred 1, 4:

• Safe hormonal profile for women with headaches 1
• Lower efficacy (5-8% failure rate) compared to LARCs 4
• Requires strict daily adherence within same 3-hour window 4
• No estrogen component to trigger headaches 1

Barrier Methods

Condoms, diaphragms, and spermicides 1:

• Completely safe with no headache risk 1
• Lower efficacy requires consistent, correct use 1
• Recommended when more effective methods are contraindicated 1

Contraceptive Methods to AVOID with Headaches

Combined estrogen-progestin contraceptives are NOT recommended 1:

• Birth control pills containing estrogen may worsen headache frequency 1, 3
• Transdermal estrogen patches should be specifically avoided 1
• Vaginal rings containing estrogen may trigger headaches 1
• Absolute contraindication if migraine with aura is present 2

Depot medroxyprogesterone acetate (DMPA/Depo-Provera) 1, 4:

• Should be avoided in patients at risk for osteoporosis 1
• Higher VTE risk (relative risk 2.67) compared to other progestin-only methods 4

Emergency Contraception Considerations

Levonorgestrel emergency contraception (Plan B) is safe for women with headaches 4, 9:

• Progestin-only formulation does not worsen headaches 4
• Should be used within 72 hours of unprotected intercourse 9
• No contraindications for women with headache history 4

Copper IUD insertion can serve as emergency contraception 1, 5:

• Effective up to 5 days after unprotected intercourse 1
• Provides ongoing contraception after emergency use 5

Clinical Implementation Algorithm

1. Determine headache type: Assess whether patient has migraine with aura (absolute contraindication to estrogen) 2

2. Offer levonorgestrel IUD as first choice: Explain <1% pregnancy rate, no headache worsening, and menstrual bleeding reduction 1, 4, 5

3. If IUD declined: Offer copper IUD (hormone-free) or progestin implant as alternatives 1, 4

4. If LARC declined: Progestin-only pills with strong counseling about daily adherence requirements 4

5. Never offer: Combined estrogen-containing contraceptives (pills, patches, rings) to women with migraine with aura 2

Important Caveats

• Women taking certain medications (efavirenz for HIV, rifampin for tuberculosis, seizure medications) may have reduced effectiveness of hormonal contraceptives and should consult their physician 9
• IUD insertion has slightly higher infection risk in first 20 days, especially with pre-existing Chlamydia infection, though routine antibiotic prophylaxis is unnecessary 5, 6
• Uterine perforation during IUD insertion is rare (0.6-16 per 1000 insertions) and risk is higher when inserted less than 4-6 weeks postpartum 5
• IUDs are safe and appropriate for nulliparous women and adolescents 6