What is the safest contraceptive option for a woman with migraine?

Contraception for Women with Migraine

Direct Answer

For women with migraine WITHOUT aura, progestin-only methods or low-dose combined hormonal contraceptives (<50 µg estrogen) are safe options; for women with migraine WITH aura, estrogen-containing contraceptives are absolutely contraindicated—use progestin-only methods or copper IUD instead. 1, 2

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Critical First Step: Determine Migraine Subtype

The single most important clinical distinction is whether the patient experiences aura (visual disturbances, sensory changes, or speech difficulties preceding headache):

• Migraine with aura = absolute contraindication to any estrogen-containing contraceptive 1, 2
• Migraine without aura = estrogen-containing contraceptives may be used if no additional stroke risk factors present 1, 3

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For Women WITH Migraine With Aura

First-Line Recommendations (Highly Effective, Stroke-Safe)

Levonorgestrel intrauterine system (LNG-IUD) is the optimal choice:

• Provides >99% contraceptive efficacy for 5-7 years without increasing stroke risk 2
• Reduces menstrual bleeding, which may decrease menstrual-related migraine attacks 2
• No contraindication per CDC guidelines 2
• Can be placed at any cycle day; backup contraception needed for 7 days if inserted >7 days after menses 2

Etonogestrel subdermal implant (Nexplanon):

• 99% effective for 3 years with no stroke risk 2

• Safe for migraine with aura per CDC 2
• Backup contraception for 7 days if inserted >5 days after menses 2

Copper IUD (ParaGard):

• Non-hormonal, >99% effective for 10-12 years 2
• No stroke risk and no migraine contraindication 2
• May increase menstrual bleeding initially 2

Second-Line Options (Lower Efficacy)

Progestin-only pills (POPs):

• Norethindrone or drospirenone formulations carry no stroke risk 2, 4
• ~90% typical-use effectiveness (requires strict daily timing within 3-hour window) 2
• May actually reduce migraine frequency and aura duration, particularly in women previously on combined hormonal contraceptives 5
• Backup contraception needed: 2 days for norethindrone if started >5 days after menses; 7 days for drospirenone if started >1 day after menses 2

Depot medroxyprogesterone acetate (DMPA/Depo-Provera):

• No stroke risk in migraine with aura 2
• ~94% typical-use effectiveness 2
• Avoid if osteoporosis risk factors present (can cause up to 7.5% bone density loss over 2 years) 2

Absolute Contraindication

All estrogen-containing contraceptives (pills, patches, vaginal rings) are prohibited:

• Women with migraine with aura using combined hormonal contraceptives have a 7-fold increased risk of ischemic stroke (RR 7.02; 95% CI 1.51-32.68) 1, 2
• Migraine with aura alone increases stroke risk 2.5-fold; estrogen amplifies this to odds ratios of 2.08-16.9 1, 2
• American Heart Association/American Stroke Association explicitly recommends against estrogen use in this population 1, 2

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For Women WITHOUT Migraine With Aura

When Combined Hormonal Contraceptives Are Safe

Combined hormonal contraceptives may be used only if ALL of the following are true:

• Age <35 years 1
• Non-smoker 1
• No hypertension 1
• No diabetes, hyperlipidemia, or thrombophilia 3
• No obesity (BMI <27.3) 1

Dose Matters

• Use formulations with <50 µg ethinyl estradiol (lower stroke risk: RR 2.08 vs. 4.53 for higher doses) 2
• Each additional 10 µg estrogen increases stroke risk by 19% (OR 1.19; 95% CI 1.16-1.23) 2

If Any Risk Factor Present

Switch to progestin-only methods (same options as migraine with aura above):

• Current users of combined oral contraceptives have increased risk of ischemic stroke compared to non-users, with risk greatest in those with hypertension, smoking, or age >35 1
• The combination of smoking + migraine + oral contraceptives creates a 9-fold stroke risk (RR 9.03; 95% CI 4.22-19.34) 1

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Managing Common Side Effects

Irregular Bleeding (Most Common with Progestin-Only Methods)

• First-line: NSAIDs for 5-7 days 2
• Second-line (only for migraine WITHOUT aura): Short course (10-20 days) of low-dose estrogen or tranexamic acid for 5 days 2
• Counsel patients upfront that irregular bleeding does NOT indicate contraceptive failure 2

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Critical Risk Factor Management

Tobacco use must be absolutely prohibited:

• Smoking + migraine with aura + estrogen = catastrophic stroke risk 2, 6
• Even without hormonal contraception, smoking + migraine with aura creates unacceptable vascular risk 1

Screen and aggressively treat hypertension:

• Combined oral contraceptives in hypertensive women increase myocardial infarction risk 6-68 fold and ischemic stroke risk 3.1-14.5 fold 1

Monitor migraine pattern:

• If migraine without aura develops aura symptoms while on combined hormonal contraceptives, immediately discontinue estrogen 3
• High migraine frequency (>weekly) in migraine with aura increases stroke risk further (HR 4.25; 95% CI 1.36-13.29) 1

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Common Pitfalls to Avoid

• Do not deny IUDs to nulliparous women or adolescents—they do not increase infertility risk 2
• Do not remove IUD for new STI diagnosis—treat infection with device in place 2
• Prior pelvic inflammatory disease is NOT a contraindication once infection is fully treated 2
• Do not use drospirenone POP in renal dysfunction or adrenal insufficiency (antimineralocorticoid activity); choose norethindrone or desogestrel instead 2
• Do not assume all "low-dose" pills are safe—even modern formulations with <50 µg estrogen remain contraindicated in migraine with aura 2, 7