Contraceptive use in women with migraine

S. K. Afridi¹

1. Corresponding author Dr Shaiza Afridi, Consultant Neurologist, Guys and St Thomas NHS Trust, London, UK

OPEN ACCESS

PUBLISHED: 30 April 2025

CITATION: Afridi, S.K. (2025). Contraceptive use in women with migraine. Medical Research Archives, [online] 13(4). http://doi.org/10.18103/mra.v13i4.623

COPYRIGHT: This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

DOI: https://doi.org/10.18103/mra.v13i4.6371

ISSN  2375-1924

Abstract

Migraine affects approximately 18% of women in childbearing age. There are a number of questions and concerns surrounding the use of contraceptives in women with migraine. This review examines the effects of various contraceptive methods and analyzes the safety concerns, in particular reviewing the existing literature regarding the safety of estrogen containing contraceptives in women with migraine.

Keywords

migraine, contraceptives, estrogen, safety, women

Introduction

Hormonal methods are either “combined”, which involves a combination of estrogen and progestogen or progestogen only. The most widely used combined contraceptive formulation is the oral contraceptive pill. There is also a vaginal ring or a patch but these are much less commonly used. With regards to estrogen only methods there is only one version available, the intrauterine device, which releases hormones.

According to the Figure 1 below, the use of contraception in women with migraine is often an issue of contentious debate and the guidelines vary and are constantly changing. This review aims to provide some context and clarification around these issues.

Methods of contraception

Hormonal methods are either “combined”, which involves a combination of estrogen and progestogen or progestogen only. The most widely used combined contraceptive formulation is the oral contraceptive pill. There is also a vaginal ring or a patch but these are much less commonly used. With regards to estrogen only methods there is only one version available, the intrauterine device, which releases hormones.

There are estrogen receptors located in the brain in areas that are thought to be important in migraine, such as the hypothalamus, pons, periaqueductal grey, locus coeruleus. In animal studies estrogen triggers cortical spreading depression which is thought to be the pathophysiological correlate of migraine aura. When a woman starts an estrogen containing contraceptive pill or initiates hormone replacement therapy or is pregnant, there is an estrogen surge and this can sometimes result in aura precipitating migraine.

The effect of contraceptives on migraine

There was no difference between the levels of PACAP between the menstrual cycle and the different phases of the menstrual cycle in women with migraine on combined contraceptives; thus, it is not very informative. In women with migraine with aura there may be an exacerbation of migraine with the combined contraceptive pill, which is perhaps linked to the effect of estrogen on cortical spreading depression.

When one is on the combined oral contraceptive pill, she will usually take it for 21 days and then have a 7-day break, during which she will have her menstrual period, and during that time she may have an increased risk of migraine. The cycling can be difficult to manage.

What are the safety concerns?

The safety concerns for migraines regarding oral contraceptives revolve around two issues; venous thromboembolism and the risk of stroke. The former is an issue regardless of migraine. The combined contraceptive pill does increase the risk of venous thromboembolism and the progestin-only contraceptive pill does not. The intrauterine contraceptive device also does not.

Conclusion

The current guidance does not take into account individual risk factors for women with migraine with aura. Further research is required to accurately assess the risk of stroke in migraines using current formulations of contraceptives and their safety in women with migraine with aura.

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