Contraception in Adolescents with Migraine

Introduction to Contraceptive Safety

The American Heart Association recommends that combined hormonal contraceptives can be used in adolescents with migraine without aura, as they are only contraindicated in migraine with aura, with careful consideration of the low-dose estrogen formulation and absence of other stroke risk factors 1, 2

The American Heart Association/American Stroke Association guidelines emphasize that lower estrogen doses minimize stroke risk, recommending lower doses of ethinyl estradiol to reduce stroke risk 1, 4
Alyssena contains 20 μg ethinyl estradiol, which falls into the lowest risk category for combined hormonal contraceptives, with each 10 μg increase in estrogen content increasing stroke risk (OR 1.19) 4
Combined hormonal contraceptives with <50 μg estrogen have significantly lower stroke risk (RR 2.08) compared to higher-dose preparations (RR 4.53) 1

The American Heart Association recommends screening for additional stroke risk factors, including tobacco use, which combined with combined hormonal contraceptives dramatically increases stroke risk and represents an absolute contraindication 5
Hypertension must be considered, as blood pressure must be normal; hypertension with combined hormonal contraceptives increases ischemic stroke risk 3.1-14.5 fold 7
Age consideration is important, while guidelines emphasize age >35 years as higher risk, adolescents like this 16-year-old fall into the lowest-risk age category 1, 2

If migraine without aura + age 16 + no tobacco + normal blood pressure + no thrombophilia = Alyssena is appropriate, according to the American Heart Association/American Stroke Association guidelines 1, 2

If there is any uncertainty or the patient develops additional risk factors, switching to progestin-only options like progestin-only pills (norethindrone or drospirenone) or the levonorgestrel IUD is recommended, as they carry no increased stroke risk 3, 4
The etonogestrel implant provides highly effective contraception without estrogen-related stroke risk, and is an alternative option 4