Contraceptive Options for Women with Migraine

Contraindicated Methods

Women with migraine with aura should avoid combined hormonal contraceptives (pills, patches, rings) entirely and use progestin-only methods instead, as combined hormonal contraceptives dramatically increase stroke risk (RR 7.02) in this population 1, 2, 3
Combined hormonal contraceptives are absolutely contraindicated in women with migraine with aura due to multiplicative stroke risk 3
Women with migraine with aura who use oral contraceptives have a 7-fold increased risk of stroke (RR 7.02; 95% CI 1.51-32.68) compared to non-users 1, 2
The risk is particularly pronounced in women under age 45 (RR 3.65; 95% CI 2.21-6.04) 1, 2
Smoking further amplifies this risk dramatically (RR 9.03; 95% CI 4.22-19.34) 1, 2
The absolute risk translates to approximately 4 additional intracranial hemorrhage events per 10,000 women per year 4, 5

Progestin-only pills are the preferred first-line contraceptive for women with migraine with aura, as they carry no increased stroke risk and may actually reduce migraine frequency 3
POPs (norethindrone) are classified as Category 1 (no restrictions) for women with migraine with aura by the CDC 6
Common side effect is irregular bleeding, which is not harmful but should be monitored 3
Avoid drospirenone-containing POPs in patients with hyperkalemia 3

Depot medroxyprogesterone acetate (DMPA) injections are safe alternatives that may reduce migraine frequency and cause amenorrhea with continued use 3
Classified as Category 2 (advantages generally outweigh risks) for migraine with aura 6
Lasts 11-13 weeks, providing reliable contraception without daily adherence requirements 6
May cause initial irregular bleeding before achieving amenorrhea 6
Levonorgestrel intrauterine device (LNG-IUD) is an excellent option that avoids systemic estrogen while managing menstrual irregularities 3
Etonogestrel implant is safe for women with migraine with aura and provides 3 years of contraception 3

Age <35 years without additional risk factors: POPs classified as Category 2 (generally safe) 6
Age ≥35 years: POPs classified as Category 3 (risks usually outweigh benefits); progestin-only methods strongly preferred 6

Absolute contraindications to combined hormonal contraceptives (use progestin-only methods only): Migraine with aura at any age 6, 3
Migraine without aura + age ≥35 years 6
Migraine + smoking 1, 2
Migraine + hypertension 7
Migraine + diabetes, hyperlipidemia, or thrombophilia 2