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Contraception for Women with Migraines

3/1/2017 - Abbey Hardy-Fairbanks, MD

Mentor:  Marygrace Elson, MD, MME

Editor:  Eduardo Lara-Torre, MD

    

Migraines headache is a common condition that affects approximately 12% of the population, and is more common in women than men. It affects 17.3-24.4% of women 18-39 years old.  A migraine is a headache lasting 4 to 72 hours and must have nausea, vomiting, or photophobia, as well as at least two of the following: unilateral location, pulsating quality, moderate to severe pain, and aggravation by routine physical activity.

Migraines can be divided into two categories, those with aura (classical) and those without (simple).  Aura is a completely reversible focal neurological sensory event that can precede or accompany the headache, come on gradually, and last no longer than one hour.  Twenty-five percent of patients with migraines experience aura.  The most common aura is visual and typically includes a bright spot or an area of visual loss. It then expands to involve a quadrant or hemifield of vision, often with “zig-zagging” lines.  Other types of aura include somatosensory phenomena, such as burning or paresthesias that migrates across one side of face or down the arm.  Less frequently, motor or verbal aura can occur.

There is an increased risk for cerebral thromboembolism (CTE) in women who use Combined Hormonal Contraception (CHC), have migraines, have hypertension, or use tobacco.  These factors have a multiplicative effect of on risk for CTE.  Women who experience migraines with aura and use CHC increase their risk of CTE three-fold, although the absolute risk is low and less than during pregnancy.

Risk for CTE per 100,000 women/years

  No CHC Taking CHC
Healthy 6 12
Migraine (no aura) 12 19
Migraine with aura 18 30
Pregnancy 34  


Migraines without aura may worsen, improve, or remain stable in women who take CHCs. While on CHCs, migraines typically occur during the hormone-free interval, and are termed estrogen withdrawal-associated headaches.  Using continuous dosing with a shortened or absent hormone free interval typically alleviates these headaches.  Menstrual migraines are considered a subtype of migraines without aura and are similar to the migraines triggered by a hormone free interval during CHC use, and will often resolve with similar interventions.  Women who start a new hormonal contraceptive should be asked to notify the provider if their headaches worsen. 

Condition Sub-Condition Cu-IUD LNG-IUD Implant DMPA POP CHC
    I C I C I C I C I C I C
Headaches a) Nonmigraine (mild or severe) 1 1 1 1 1 1*
b) Migraine            
 i) Without aura (includes menstral migraine) 1 1 1 1 1 2*
 ii) With aura 1 1 1 1 1 4*

1=no restriction for the use of the contraceptive method; 2=Advantages of using the method generally outweigh the theoretical or proven risks; 3=theoretical or proven risks usually outweigh the advantages of the method; 4=unacceptable health risk if the contraceptive method is used.*

Further Reading:

Curtis KM, Tepper NK, Jatlaoui TC, et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. MMWR Recomm Rep 2016;65(No. RR-3):1–104.

Noncontraceptive uses of hormonal contraceptives. Practice Bulletin No. 110. American College of Obstetricians and Gynecologists. Obstet Gynecol 2010;115:206–18.

Tepper NL, Whiteman MK, Zapata LB, Marchbanks PA, Curtis KM Safety of hormonal contraceptives among women with migraine: a systematic review. Contraception 2016;94(6):630-40.

Initial Approval:  January 2017

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