What contraceptive method is preferred for a woman with hormonal migraines without aura?

Contraception for Hormonal Migraines Without Aura

Progestin-only contraceptives—specifically the levonorgestrel intrauterine system (LNG-IUD), etonogestrel implant, or progestin-only pills—are the preferred contraceptive options for women with hormonal migraines without aura, as they avoid estrogen-related stroke risk while potentially reducing migraine frequency by eliminating estrogen-withdrawal triggers. 1

First-Line Highly Effective Options

Levonorgestrel Intrauterine System (LNG-IUD)

• The LNG-IUD is the optimal first choice because it markedly reduces menstrual blood loss and often induces amenorrhea, which can lower the frequency of menstrual-related migraine attacks by removing estrogen-withdrawal triggers. 1
• Provides >99% contraceptive effectiveness for 5–7 years without requiring daily adherence. 1
• Carries no stroke risk and is classified as Category 1 (no restrictions) by the CDC for women with migraine without aura. 2, 1
• Irregular bleeding is common initially; manage with NSAIDs for 5–7 days as first-line therapy. 1

Etonogestrel Subdermal Implant

• Offers >99% contraceptive effectiveness for 3 years without estrogen-related stroke risk. 1
• Safe for women with migraine without aura per CDC guidance. 1
• If inserted >5 days after menses, backup contraception is needed for 7 days. 1
• For bothersome bleeding, use NSAIDs for 5–7 days; if persistent, consider brief low-dose estrogen (10–20 days) or tranexamic acid for 5 days. 1

Copper Intrauterine Device (Cu-IUD)

• Non-hormonal option with >99% effectiveness for 10–12 years and no stroke risk. 1
• No migraine contraindication and no backup contraception required regardless of cycle timing. 1
• May initially increase menstrual bleeding and cramping, which could worsen menstrual migraine triggers. 1

Second-Line Options

Progestin-Only Pills (POPs)

• Norethindrone or drospirenone POPs are safe with respect to stroke risk and may actually reduce migraine frequency. 1, 3
• Effectiveness is lower (~90% typical use) than LARCs because strict daily timing within a 3-hour window is required. 1
• Preliminary evidence suggests desogestrel 75μg POP reduces the number of migraine days, analgesic use, and intensity of associated symptoms in the majority of women with migraine without aura. 3
• If started >5 days after menses (norethindrone) use backup contraception for 2 days; if drospirenone, use backup for 7 days if started >1 day after menses. 1

Depot Medroxyprogesterone Acetate (DMPA)

• Does not increase stroke risk in women with migraine without aura. 1
• Provides ~94% typical-use effectiveness with injections every 3 months. 1
• Conditionally discouraged if osteoporosis risk factors are present, as bone mineral density may decline up to 7.5% over two years. 1
• If initiated >7 days after menses, backup contraception is required for 7 days. 1

When Combined Hormonal Contraceptives May Be Considered

Combined hormonal contraceptives (CHCs) may be used ONLY if ALL of the following criteria are met: 1

• Age <35 years
• Non-smoking status
• Absence of hypertension
• Body mass index <27.3 kg/m²

If any single risk factor is present, CHCs should be avoided and a progestin-only method or copper IUD should be offered instead. 1

Critical Risk Considerations

• Concurrent smoking, migraine, and CHC use produce a synergistic effect yielding a ~9-fold increase in stroke risk (RR 9.03; 95% CI 4.22–19.34). 1
• Hypertension in CHC users increases myocardial infarction risk by 6–68 fold and ischemic stroke risk by 3.1–14.5 fold. 1
• If aura symptoms emerge while using CHCs, immediately discontinue estrogen-containing products, as migraine with aura is an absolute contraindication to estrogen. 4

Managing Oral-Contraceptive-Induced Menstrual Migraine (OCMM)

If migraine attacks occur primarily during the pill-free week on CHCs: 5

• Use a continuous CHC regimen to eliminate the hormone-free interval
• Shorten the hormone-free interval to <7 days
• Add low-dose estrogen supplementation during the traditional 7-day break
• Switch to a progestin-only pill, which eliminates estrogen withdrawal entirely 5

Essential Counseling and Monitoring

• Tobacco use must be absolutely prohibited in women with migraine, as smoking combined with migraine creates catastrophic stroke risk even without hormonal contraception. 1
• Screen for and aggressively manage hypertension, a modifiable stroke risk factor. 1
• Arrange regular follow-up to monitor any changes in migraine pattern or frequency; emergence of aura symptoms requires immediate contraceptive reassessment. 1
• Counsel all patients on consistent condom use for STI prevention, regardless of the chosen contraceptive method. 1
• Irregular bleeding with progestin-only methods should be discussed upfront; reassure patients that such bleeding does not indicate contraceptive failure. 1