Women have a higher risk of experiencing migraine compared to men, primarily due to hormonal fluctuations and genetic factors. Migraine often persists as a lifelong disorder, particularly troublesome for women during their reproductive years—from the onset of menstruation to menopause. This period exposes women to oral contraceptive pills and other hormonal treatments for contraception, which can potentially exacerbate migraine symptoms.
If you’re living with migraines and considering contraception, here are some important factors to keep in mind.
Is it possible for a contraceptive pill to make migraine worse?
Using an oral contraceptive pill or any hormonal treatment can either improve, worsen, or have no effect on your migraine pattern. The impact is unpredictable. Worsening of migraine is typically seen when taking sugar pills, but sometimes it is not that clear.
Consider using a migraine diary to monitor attack frequency. Migraine has a natural tendency to fluctuate, and it may take 2 to 3 months for the situation to stabilize.
Family physicians will sometimes try to switch contraceptives to improve migraine, but this is not a well-established approach. Anecdotal reports of migraine improvement after stopping oral contraceptives exist, but the outcome is difficult to predict.
Are there contraceptive pills that are better for women with menstrual migraine?
Migraine associated with the drop in estrogen levels of the natural menstrual cycle is called “menstrual migraine,” affecting 1 in 5 women with migraine. If you use a contraceptive pill with a sugar week that mimics the natural drop, it may trigger migraine as well. If you experience migraine related to your menstrual cycle, consider using a continuous oral contraceptive without a sugar pill week or with a lower drop in estrogen dose. This approach has been well-studied for menstrual migraine management.
What about the progestin-only pills? Could they affect migraine frequency?
Progesterone-only contraceptive pills (such as Micronor) or arm implants (such as Depo Provera) can be safely used in women with migraine with and without aura and do not appear to increase the risk of clots or stroke. However, research on whether progesterone-only contraceptives help reduce migraine is inconclusive.
I am considering an intrauterine device (IUD). Could this worsen migraine?
The World Health Organization considers the IUD as safe as progesterone-only pills for migraine with aura, but there is not enough research to confidently determine whether it will worsen your migraine.
Is it true that migraine is associated with stroke? Can I still use contraceptive pills?
In general, women with migraine with aura are believed to have a 2 to 4-times greater risk of stroke compared to those without aura. Estrogen also increases the risk of stroke in young women. For this reason, contraceptives with estrogen are better avoided in women with migraine with aura. However, many alternative contraceptive options are available.
While considering this risk may be daunting, it’s important to note that the overall risk of stroke for reproductive-age women is relatively low (about 1 in 10,000 per year). However, the risk increases with additional factors such as age, high blood pressure, smoking, and diabetes. In women over 50, migraine with aura no longer appears to be a significant risk factor as other factors become more important.
Which contraceptive is considered higher risk versus lower risk for stroke in women with migraine?
The European Headache Federation and European Society of Contraception and Reproductive Health ranked the following contraceptives based on stroke risk in women with migraine:
**Please consult your doctor to determine what method of contraception is best for you**
What should I do if my migraine changes or if I start to experience auras after starting oral contraception?
In general, headache specialists recommend that if you are taking contraception and develop prolonged auras, new types of auras, or suddenly develop migraine with aura, you should stop taking the oral contraceptive pill and see your family doctor urgently for further advice.
I am considering pregnancy. Can I just stop my contraceptives?
Any person considering pregnancy should inform their family doctor before stopping contraceptives. Pregnancy planning is also very important to discuss with your doctor as you may be taking medications that could be harmful to the unborn baby. Planning for pregnancy is key to allow your doctor to switch you to a medication found to be safer to use during pregnancy. For additional information, please see our post on pregnancy and migraine.
References
- Calhoun AH, Batur P. Combined hormonal contraceptives and migraine: An update on the evidence. Cleveland Clinic journal of medicine. 2017;84(8):631-8.
- Warhurst S, Rofe CJ, Brew BJ, Bateson D, McGeechan K, Merki-Feld GS, et al. Effectiveness of the progestin-only pill for migraine treatment in women: A systematic review and meta-analysis. Cephalalgia : an international journal of headache. 2018;38(4):754-64.
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