Which contraceptive method is contraindicated in a 22‑year‑old woman with migraine with aura and recent pelvic inflammatory disease?

Combined Hormonal Contraceptives (CHCs) Are Absolutely Contraindicated

Combined hormonal contraceptives containing estrogen—including pills, patches, and vaginal rings—are absolutely contraindicated in this 22-year-old woman with migraine with aura. 1, 2

Why Estrogen-Containing Methods Are Contraindicated

Stroke Risk Amplification

• Migraine with aura alone increases ischemic stroke risk 2.5-fold compared to women without migraine 1
• When combined with estrogen-containing contraceptives, the stroke risk increases dramatically with odds ratios ranging from 2.08 to 16.9 1, 2
• Women with migraine with aura using estrogen contraceptives have a 7-fold increased risk of ischemic stroke (RR 7.02; 95% CI 1.51-32.68) 3
• The American Heart Association/American Stroke Association explicitly recommends against using estrogen-containing contraceptives in individuals with migraine with aura 1, 3
• This represents a CDC U.S. Medical Eligibility Criteria Category 4 contraindication (unacceptable health risk) 4, 5

Clinical Reality Check

Despite clear contraindications, studies show that 39% of women with medical contraindications to estrogen (81% of whom had migraine with aura) were inappropriately using combined hormonal contraceptives 5. This highlights the critical importance of proper screening and counseling.

Safe Contraceptive Options for This Patient

First-Line Highly Effective Options

Levonorgestrel IUD (LNG-IUD):

• Provides highly effective contraception without stroke risk 1, 2
• No contraindication related to migraine with aura 6
• May reduce menstrual bleeding, which can be beneficial if she has heavy periods 6
• Regarding PID: The recent PID diagnosis does NOT contraindicate IUD placement once the infection is treated 6
• IUD can be placed anytime; if >7 days after menses started, backup contraception needed for 7 days 6

Etonogestrel Implant:

• Provides highly effective contraception without estrogen-related stroke risk 1
• No contraindication for migraine with aura 6
• Can be placed anytime; if >5 days after menses, backup contraception needed for 7 days 6
• Studies in women with migraine with aura showed reduced migraine attack frequency with progestin-only methods 7

Copper IUD (Cu-IUD):

• Highly effective non-hormonal option with no stroke risk 1, 2
• No contraindication for migraine with aura 6
• No backup contraception needed regardless of cycle timing 6
• May increase menstrual bleeding and cramping initially 6

Second-Line Options

Progestin-Only Pills (POPs):

• Norethindrone or drospirenone-containing POPs are safe options with no increased stroke risk 1, 2
• Less effective than LARCs due to strict adherence requirements (must be taken same time daily) 2
• Norethindrone/norgestrel POP: backup contraception for 2 days if started >5 days after menses 6
• Drospirenone POP: backup contraception for 7 days if started >1 day after menses 6
• A prospective study showed POPs reduced migraine attack frequency in women with migraine with aura (from 3.9±1.0 to 2.9±0.8 attacks; p<.001) 7

DMPA (Depot Medroxyprogesterone Acetate):

• Safe regarding stroke risk in migraine with aura 6
• However, conditionally recommend against if she has any risk factors for osteoporosis, as bone mineral density can decline up to 7.5% over 2 years 6
• If used: backup contraception for 7 days if started >7 days after menses 6

Managing Common Side Effects

Irregular Bleeding with Progestin Methods

• Irregular bleeding is the most common side effect and should be discussed upfront to improve adherence 1, 2
• For LNG-IUD or implant users with bothersome bleeding: NSAIDs for 5-7 days 6
• For implant users with heavy/prolonged bleeding: consider short courses of low-dose estrogen (10-20 days) or tranexamic acid (5 days) 6

Critical Additional Counseling Points

Absolute Risk Factor Elimination

• Absolutely prohibit tobacco use—smoking combined with migraine with aura creates catastrophic stroke risk even without hormonal contraceptives 3
• Screen for and aggressively manage hypertension 1, 3
• Assess other stroke risk factors including hyperlipidemia, obesity, and diabetes 8

Migraine Monitoring

• Regular follow-up to monitor changes in migraine pattern or frequency 1
• If she develops new neurological symptoms or increased aura frequency, urgent evaluation is needed 4

PID Considerations

• The recent PID diagnosis does not contraindicate IUD placement once infection is adequately treated 6
• Studies in immunocompromised women (HIV-positive, transplant recipients) show no increased IUD-associated infection risk 6
• Counsel on condom use for STI prevention regardless of contraceptive method chosen 6