Contraception for Women with Migraines
Mentor: Marygrace Elson, MD, MME
Editor: Eduardo Lara-Torre, MD
Migraine 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 on risk for CTE. Women who experience migraines with aura and use CHC increase their risk of CTE two-fold, although the absolute risk is low and less than during pregnancy. It is recommended that women with a history of migraine with aura use contraceptive methods that do not include estrogen (see table for alternatives).
Risk for CTE per 100,000 women/years
|No CHC||Taking CHC|
|Migraine (no aura)||12||19|
|Migraine with aura||18||30|
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.
|Headaches||a) Nonmigraine (mild or severe)||1||1||1||1||1||1*|
|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.
Curtis KM, Tepper NK, Jatlaoui TC, et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. MMWR Recomm Rep. 2016 Jul 29;65(3):1-103. doi: 10.15585/mmwr.rr6503a1.
American College of Obstetricians and Gynecologists, ACOG Practice Bulletin No. 110: noncontraceptive uses of hormonal contraceptives. Obstet Gynecol. 2010 Jan;115(1):206-18. doi: 10.1097/AOG.0b013e3181cb50b5.
Tepper NL, Whiteman MK, Zapata LB, et al, Safety of hormonal contraceptives among women with migraine: A systematic review. Contraception 2016;94(6):630-40.
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This document is designed to aid practitioners in providing appropriate obstetric and gynecologic care. Recommendations are derived from major society guidelines and high quality evidence when available, supplemented by the opinion of the author and editorial board when necessary. It should not be construed as dictating an exclusive course of treatment or procedure to be followed.
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