Is the levonorgestrel‑releasing intrauterine system (Mirena) suitable for a woman with stable migraine without aura?

Mirena IUD is Excellent for Women with Stable Migraine

The levonorgestrel-releasing intrauterine system (Mirena) is a first-line, highly effective contraceptive option for women with stable migraine, including migraine with aura, because it carries no increased stroke risk and may actually reduce menstrual-related migraine attacks. 1

Why Mirena is Ideal for Migraine Patients

No Stroke Risk

• The CDC classifies the levonorgestrel IUD as Category 1 (no restrictions) for women with migraine with aura, meaning it is completely safe from a cerebrovascular standpoint 1
• Unlike estrogen-containing contraceptives, which increase stroke risk 7-fold in migraine with aura patients (RR 7.02; 95% CI 1.51–32.68), progestin-only methods like Mirena carry no such risk 1, 2
• This makes Mirena safer than combined hormonal contraceptives even for migraine without aura when additional stroke risk factors are present 3, 4

Additional Benefits for Migraine Sufferers

• Mirena reduces overall menstrual bleeding and often leads to amenorrhea, which can decrease menstrual migraine frequency by eliminating estrogen withdrawal triggers 5, 1
• Women with painful menses experience significant symptom improvement with the levonorgestrel IUD 5
• The stable, low-dose progestin delivery avoids the hormonal fluctuations that can trigger migraine attacks 6, 7

Practical Advantages

• Provides highly effective contraception (failure rate <1%) for 5–7 years without requiring daily adherence 5
• Can be inserted at any point in the menstrual cycle; if placed >7 days after menses onset, backup contraception is needed for only 7 days 1
• No routine follow-up visits are required beyond advising women when removal is needed 5

Managing Common Side Effects

Irregular Bleeding

• Irregular bleeding is the most common side effect of progestin-only methods; counsel patients upfront that this does not indicate contraceptive failure 1
• For bothersome unscheduled bleeding, prescribe NSAIDs for 5–7 days as first-line treatment 5, 1
• If bleeding persists despite NSAIDs, consider a brief course (10–20 days) of low-dose estrogen or combined oral contraceptives only if the patient has migraine without aura 5

Critical Safety Considerations

What to Screen For

• Absolutely prohibit tobacco use – smoking combined with migraine creates catastrophic stroke risk even without hormonal contraception 1, 2, 8
• Screen for and aggressively manage hypertension, as it compounds baseline stroke risk in migraine patients 1, 2, 8
• Prior pelvic inflammatory disease does not contraindicate IUD insertion once the infection is fully treated 1

When to Check Strings

• Consider performing an examination to check for IUD strings at routine visits, though no specific follow-up schedule is mandated 5

Common Pitfalls to Avoid

• Do not withhold Mirena from nulliparous women – IUDs are safe for adolescents and do not cause tubal infertility 5
• Do not remove the IUD for a new STI diagnosis – treat the infection without removing the device 5
• The small risk of pelvic infection is limited to the first 21 days after insertion 5
• Women who are immunocompromised (HIV-positive, transplant recipients) do not have increased risk of IUD-associated infection 1

Alternative Progestin-Only Options

If Mirena is declined or contraindicated, other stroke-safe options include:

• Etonogestrel implant (Nexplanon): 3-year duration, >99% effective, safe for migraine with aura 5, 1
• Copper IUD (ParaGard): Non-hormonal, 10–12 years duration, no stroke risk, but may increase menstrual bleeding 5, 1
• Progestin-only pills: Lower effectiveness (~90% typical use) due to strict daily timing requirements; norethindrone is preferred over drospirenone for most patients 1
• DMPA injection: Safe for migraine with aura but conditionally discouraged if osteoporosis risk factors are present (bone density may decline 7.5% over 2 years) 1