Contraception and Migraine with Aura Guidelines

Contraindications and Safe Alternatives

• Women with migraine with aura have a significantly elevated baseline risk of ischemic stroke compared to those without aura, and combined hormonal contraceptives are contraindicated due to this compounded stroke risk 1
• The American College of Obstetricians and Gynecologists and the American Headache Society explicitly state that combined hormonal contraceptives are contraindicated in women with migraine with aura due to this compounded stroke risk 1
• Progestin-only contraceptives are generally considered safe alternatives for women with migraine with aura because they do not carry the same stroke risk as estrogen-containing products 1
• Progestin-only methods, including progestin-only pills like Slinda, are appropriate alternatives when combined hormonal contraceptives are contraindicated 1
• All combined hormonal contraceptives containing estrogen must be avoided in women with migraine with aura 1

Managing Migraine with Aura

• Start NSAIDs or aspirin as soon as possible during the aura phase to prevent or diminish the subsequent headache 2, 3
• If NSAIDs fail, use triptans when the headache begins—but not during the aura phase itself 1
• First-line preventive medications include propranolol, metoprolol, or topiramate 1

Monitoring and Evaluation

• Evaluate treatment response within 2-3 months after initiation using headache calendars to track attack frequency, severity, and medication use 1
• Watch for medication overuse headache, which can develop from using acute medications more than twice weekly 2, 3