Contraception for Female Smokers with Migraine
For a female smoker with migraine, long-acting reversible contraceptives (LARCs)—specifically the levonorgestrel-releasing IUD, copper IUD, or etonogestrel implant—are the recommended contraceptive methods, while combined hormonal contraceptives (pills, patches, rings) should be avoided due to increased cardiovascular and stroke risk. 1
Why Combined Hormonal Contraceptives Are Contraindicated
The U.S. Medical Eligibility Criteria (US MEC) classification system uses a 4-point scale where Category 4 represents an unacceptable health risk. 1
Combined hormonal contraceptives (COCs, patch, ring) are classified as Category 3 or 4 for women with migraine, particularly when combined with smoking, due to elevated thrombotic and stroke risk. 1
- The combination of smoking and migraine creates additive cardiovascular risk that makes estrogen-containing methods unsafe 1
- Estrogen in combined hormonal contraceptives increases the risk of cardiovascular events, which is further amplified in smokers 2
Recommended First-Line Options: LARCs
Long-acting reversible contraceptives are the optimal choice, offering superior efficacy (failure rates 0.2-0.8% per year) without cardiovascular contraindications. 1, 3
Specific LARC Options:
- Levonorgestrel-releasing IUD (LNG-IUD): Pregnancy rates <1% per year, no cardiovascular restrictions for smokers or women with migraine 1, 3
- Copper IUD: Failure rate 0.8% per year, completely hormone-free option 1, 3
- Etonogestrel implant: Failure rate 0.05% per year, progestin-only with no estrogen-related risks 1
These methods are classified as Category 1 (no restriction for use) for both smoking and migraine conditions. 1
Alternative Options: Progestin-Only Methods
If LARCs are declined or unavailable, progestin-only contraceptives are acceptable alternatives:
- Progestin-only pills (POPs): Typical-use failure rate 3-8% per year, safe for smokers with migraine 1, 2, 4
- Depot medroxyprogesterone acetate (DMPA): Injectable every 3 months, no cardiovascular contraindications in this population 1, 4
These progestin-only methods lack the estrogen component that creates cardiovascular risk, making them Category 1 or 2 for smokers with migraine. 1
Important Caveat:
Progestin-only pills require strict adherence (same time daily) and have higher typical-use failure rates compared to LARCs, making them less ideal despite being medically safe. 2, 4
Barrier Methods as Backup
Barrier methods (condoms, diaphragm) are Category 1 for all women but have significantly higher failure rates (typical use 12-18% per year), making them inadequate as sole contraception for most women. 1
Emergency Contraception Considerations
If emergency contraception is needed:
- Copper IUD insertion within 5 days: Most effective option (>95% prevention), also provides ongoing contraception 5, 3
- Ulipristal acetate (30 mg): Effective within 120 hours, no contraindications for smokers with migraine 5
- Levonorgestrel (1.5 mg): Safe but less effective than ulipristal acetate, especially after 72 hours 5
Clinical Implementation Algorithm
First, assess migraine type: Migraine with aura carries higher stroke risk than migraine without aura, but both contraindicate combined hormonal contraceptives in smokers 1
Offer LARC as first-line: Counsel on LNG-IUD, copper IUD, or implant based on patient preference 1, 3
If LARC declined: Offer progestin-only pills or DMPA injections 1, 4
Avoid entirely: Combined oral contraceptives, contraceptive patch, vaginal ring 1, 2
No examinations required before initiating: Progestin-only methods and IUDs are Class C (not needed) for most examinations; only bimanual exam is Class A (essential) for IUD insertion 1
Common Pitfalls to Avoid
- Do not prescribe combined hormonal contraceptives even if the patient requests them—the cardiovascular risk outweighs patient preference in this scenario 1
- Do not delay LARC initiation waiting for menses—quick start is appropriate if reasonably certain the patient is not pregnant 1
- Do not require unnecessary testing before contraception initiation—blood pressure, lipids, glucose, and thrombogenic mutation testing are Class C (not needed) for progestin-only methods and IUDs 1