In an 18‑year‑old woman with chronic bilateral lower‑abdominal pain that worsens with menses, currently on combined oral contraceptives despite migraine with aura, what is the appropriate contraceptive choice and next management steps?

Immediate Contraceptive Change Required

This patient must discontinue combined oral contraceptives immediately because migraine with aura is an absolute contraindication to combined hormonal contraception due to increased stroke risk. 1, 2

Critical Safety Issue: Combined OCP and Migraine with Aura

• Combined oral contraceptives are contraindicated in all women with migraine with aura, regardless of age or other risk factors. 1, 2
• The presence of right-sided headaches with suspected aura symptoms makes continued use of the combined pill unsafe, even though it provided mild improvement in bleeding. 1
• This contraindication applies to all combined hormonal methods (pills, patches, and vaginal rings). 1

Recommended Contraceptive Switch

Switch immediately to a progestogen-only pill (mini pill), which she was previously taking. 3

• Progestogen-only contraceptives are safe in migraine with aura and may actually reduce both migraine frequency and aura duration. 3
• The levonorgestrel IUD is another excellent option that provides local progestin delivery with minimal systemic effects and has demonstrated efficacy for heavy menstrual bleeding. 1
• Both options avoid the stroke risk associated with estrogen-containing contraceptives in migraine with aura patients. 1, 3

Next Diagnostic Steps for Pelvic Pain

Immediate Evaluation Required

Obtain transvaginal ultrasound with color Doppler to evaluate for endometriosis, adenomyosis, ovarian pathology, and structural abnormalities. 4

• The bilateral lower abdominal pain worsening with menses, lasting months despite treatment, and connection to ovaries/endometrium strongly suggests endometriosis or adenomyosis. 4
• Ultrasound should be performed because pain has not improved after 2-3 cycles of appropriate therapy (tranexamic acid and mefenamic acid). 4
• Always perform serum β-hCG testing first to rule out pregnancy-related causes before further workup. 4

If Ultrasound is Non-Diagnostic

Order MRI pelvis if endometriosis is suspected, which has 90% sensitivity and 91% specificity for this diagnosis. 4

• MRI is the second-line imaging modality when ultrasound findings are equivocal or when detailed assessment of adenomyosis is needed. 4
• CT abdomen/pelvis with IV contrast is reserved for equivocal ultrasound findings in acute presentations. 4

Pain Management Strategy

First-Line Treatment

Optimize NSAID therapy with scheduled dosing: ibuprofen 600-800 mg every 6-8 hours with food or naproxen 440-550 mg every 12 hours for 5-7 days during symptomatic periods. 4

• She is already taking mefenamic acid, but ensure she is using therapeutic doses consistently, not just as needed. 4
• Approximately 18% of patients do not respond to NSAIDs, which should trigger evaluation for secondary causes. 4
• Common pitfall: Do not under-dose NSAIDs; use the recommended therapeutic doses from the start. 4

Adjunct Non-Pharmacologic Measures

Add heat application to abdomen/back, acupressure at LI4 and SP6 points, and topical peppermint essential oil. 4

Second-Line Hormonal Options (After Contraceptive Switch)

If NSAIDs remain ineffective after switching to progestogen-only contraception, consider GnRH analogues for recurrent attacks. 4

• GnRH analogues initiated early in the cycle suppress ovulation and corpus luteum formation. 4
• Low-dose estradiol patches may be introduced after three months to mitigate menopausal symptoms and bone loss. 4
• This approach is appropriate if imaging confirms endometriosis or if pain persists despite adequate NSAID therapy. 1

Migraine-Specific Management

Acute Migraine Treatment

Prescribe NSAIDs (ibuprofen, naproxen, or diclofenac potassium) as first-line acute treatment for migraine attacks. 5

• Triptans should be offered when NSAIDs provide inadequate relief, taken early when headache is still mild. 5
• She can safely use triptans even with migraine with aura for acute treatment (the contraindication applies only to combined hormonal contraceptives, not triptans). 1

Migraine Prevention

If she requires daily migraine prevention, initiate β-blockers (metoprolol or propranolol), amitriptyline, or venlafaxine as first-line agents. 5

• CGRP-targeted therapies (oral gepants or monoclonal antibodies) are second-line options if first-line agents fail. 5
• Topiramate is reserved as third-line after adequate trials of both first-line and CGRP-targeted therapies. 5
• Caution: Avoid topiramate in women of childbearing potential due to teratogenic risk. 1

Common Pitfalls to Avoid

• Never continue combined hormonal contraceptives in a patient with migraine with aura, even if other symptoms improve. 1, 2
• Do not delay imaging beyond 2-3 cycles if pain persists despite optimized NSAID therapy. 4
• Always rule out pregnancy before initiating any new treatment or imaging in reproductive-age women. 4
• Do not assume all pelvic pain is gynecologic; 15-25% originates from gastrointestinal or urologic sources. 4
• Recognize that approximately 10% of patients fail both NSAIDs and hormonal contraception and require further investigation. 4

Immediate Action Plan

1. Discontinue combined oral contraceptive today 1
2. Restart progestogen-only pill or place levonorgestrel IUD 3, 1
3. Order serum β-hCG and transvaginal ultrasound with Doppler 4
4. Optimize scheduled NSAID dosing for pain management 4
5. Refer to neurology for migraine with aura management if headaches persist 1
6. Consider gynecology referral if imaging suggests endometriosis or adenomyosis 1