Contraception and Migraine With Aura

Migraine with aura is a recurrent headache disorder preceded or accompanied by fully reversible focal neurological symptoms, most often visual (flickering lights, zigzag lines, scotoma), then sensory (spreading numbness or tingling) or speech disturbance, evolving over 5 to 60 minutes. It roughly doubles the baseline risk of ischaemic stroke, and oestrogen multiplies that risk, so oestrogen-containing methods are not used.

Identifying aura. Ask every patient with headache whether any visual, sensory or speech disturbance comes before or with the headache, how long it lasts, and whether it spreads gradually. Headache with no aura or non-migrainous headache does not carry this restriction.

Assessment. Age, smoking, blood pressure, BMI, past stroke or transient ischaemic attack, family history of early stroke, current contraceptive, and whether aura began or worsened on a hormonal method. New aura, prolonged aura over 60 minutes, motor weakness or brainstem symptoms need neurological evaluation.

Menstrual migraine. Attacks linked to the hormone-free interval of a pill are common; continuing the pill without a break does not make oestrogen safe in aura.

Effectiveness. First-year pregnancies per 100 women with typical use: implants 0.05, intrauterine devices 0.2 to 0.8, injectables 3, progestin-only pills about 8.

Eligibility.

Method comparison. The copper device has no hormonal effect and is the safest. The levonorgestrel device, implants and DMPA are acceptable after counselling. Progestin-only pills are acceptable but need strict timing.

Stopping rules. Stop a combined method at once if aura appears or the pattern worsens. If aura starts or worsens on an implant or levonorgestrel device, advise removal and a non-hormonal method.

Special groups. Smokers, patients over 35 years, and those with hypertension have additive stroke risk. Women with a history of stroke are category 4 for combined methods and need specialist advice for any hormonal method.

Regimen lines.

• Copper T 380A: up to 12 years; insert within 12 days of the start of bleeding or at any time if reasonably not pregnant; no backup.

• Levonorgestrel 52 mg device: 5 years; same start rule.

• Etonogestrel 68 mg rod: 3 years; levonorgestrel two 75 mg rods: 5 years or 3 years by system; backup 7 days if inserted after day 7 of bleeding.

• DMPA 150 mg intramuscularly every 13 weeks, up to 4 weeks late, or 104 mg subcutaneously every 13 weeks, up to 4 weeks late; backup 7 days if started after day 7.

• Progestin-only pill: one tablet daily without a break; late window 3 hours for the traditional pill, 12 hours for desogestrel and 24 hours for drospirenone; backup 2 days after a late or missed pill.

• Combined methods: not used.

Acute migraine treatment. Paracetamol 1 g orally every 6 hours up to 4 g daily, or ibuprofen 400 mg orally every 6 to 8 hours up to 1.2 g daily, with an antiemetic if needed. Triptans are not contraceptive-interacting but are avoided in hemiplegic or brainstem aura and in vascular disease.

Switching from a combined method. Stop the combined method, start the new method the same day, and use backup 7 days unless the new method is a copper device or the patient is within 7 days of the start of bleeding.

Follow up. Review headache pattern at 3 months and at each visit; teach the patient to report any new aura or neurological symptom immediately.

Stroke. Sudden weakness, facial droop, speech disturbance, visual loss or severe sudden headache is an emergency; stop any hormonal method and transfer for imaging.

Worsening migraine. More frequent or prolonged aura on a progestin method needs medicine review, exclusion of secondary causes, and removal if it persists.

Bleeding on progestin methods. Ibuprofen 800 mg three times daily for 5 days, taken with food, if no peptic ulcer or kidney impairment; tranexamic acid 500 mg three times daily for 5 days is avoided if thrombosis risk is present.

Red flags. New focal deficit, aura over 60 minutes, thunderclap headache, headache with fever or papilloedema.

Referral and escalation. Refer first aura after starting a hormonal method, atypical aura and any suspected stroke or transient ischaemic attack urgently.