Praxis Medical Insights

Est. 2024 • Clinical Guidelines Distilled

Made possible by volunteer editors from the University of Calgary & University of Alberta

Last Updated: 9/10/2025

Contraceptive Options and Migraine Management for Women with Migraine with Aura

  • The Centers for Disease Control and Prevention recommends progestin-only pills (POPs) as the first choice for women with migraine with aura and menstrual irregularities, as they do not increase stroke risk and can help manage menstrual irregularities 3, 4
  • The Centers for Disease Control and Prevention advises avoiding drospirenone-containing POPs in patients with hyperkalemia 3
  • Depot medroxyprogesterone acetate (DMPA) injections can be considered as an alternative option, as they may reduce migraine frequency and lead to amenorrhea with continued use 5
  • The Centers for Disease Control and Prevention suggests levonorgestrel intrauterine device (LNG-IUD) as a safe option that can help with menstrual irregularities while avoiding systemic estrogen 3
  • Implantable contraceptives (etonogestrel implant) are safe for use in women with migraine with aura 3

Management of Migraine Prophylaxis

  • The American Academy of Neurology recommends beta-blockers (propranolol 80-160 mg daily, metoprolol 50-100 mg twice daily) as first-line migraine preventive medications 1, 6, 7
  • Candesartan (16-32 mg daily) can be considered if beta-blockers are contraindicated 1, 6
  • Amitriptyline (10-100 mg at night) is a second-line option for migraine prophylaxis 1, 6
  • Topiramate (50-100 mg daily) is a second-line option, but is contraindicated in pregnancy 1, 6
  • The American Headache Society recommends NSAIDs (naproxen) for perimenstrual prevention, starting 2 days before expected menstruation 1, 2
  • Long-acting triptans (frovatriptan, naratriptan) can be used perimenstrually for 5 days 1, 2

Important Considerations and Contraindications

  • The American College of Obstetricians and Gynecologists states that combined hormonal contraceptives (pills, patches, rings) are contraindicated in women with migraine with aura due to increased stroke risk 1, 2, 3
  • Sodium valproate is absolutely contraindicated in women of childbearing potential 1, 2, 6

Monitoring and Follow-up

  • The American Academy of Neurology recommends evaluating response to treatment within 2-3 months of initiation 1
  • Headache calendars should be used to track attack frequency, severity, and medication use 1
  • Breakthrough bleeding with POPs is common but generally not harmful, and should be monitored 5

REFERENCES

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