Finding the right form of birth control can take some trial and error. It’s definitely not one-size-fits-all, says Julie M. Levitt, MD, an obstetrician-gynecologist at The Women’s Group of Northwestern in Northbrook, Illinois. “I would never say, ‘Oh, this one method or pill is my go-to for everybody; it has to be very individualized and tailored to that patient,” says Dr. Levitt. There can also be concerns about the safety of some types of hormonal birth control for women with migraine or the risk that some contraception medications could affect your hormone levels in a way that makes your migraine attacks worse. Here’s some expert advice on evaluating your birth control options if you have migraine.
Different Types of Hormonal Birth Control
There are several available methods of hormonal birth control to choose from, according to Planned Parenthood. They include the following options:
Birth Control Pills There are two kinds of birth control pills: combination pills (COCs) and progestin-only pills (PPPs). COCs contain synthetic forms of the hormones estrogen and progestin, and PPPs (also called minipills) have just progestin without estrogen. Birth control pills typically need to be taken every day.Birth Control Implant This tiny device, brand-named Nexplanon, releases progestin into the body. The implant is usually placed in the upper arm and prevents pregnancy for up to three years. It must be inserted and removed by a healthcare provider.IUD IUD stands for intrauterine device, and there are two types: copper and hormonal. The hormonal type releases progestin into the body. Both types must be inserted into the uterus by a healthcare professional. The one copper IUD on the market, Paragard, provides up to 10 years of pregnancy prevention, while the four available hormonal IUDs — Liletta, Mirena, Kyleena, and Skyla — provide between 3 and 6 years of pregnancy prevention.Birth Control Shot Also called the Depo shot, short for the brand name Depo-Provera, this injection contains progestin. It needs to be injected every three months by a healthcare provider.Birth Control Ring Known as the NuvaRing, the birth control ring is placed in the vagina, where it releases estrogen and progestin. It’s inserted by the user once a month and removed after three weeks. A new ring is inserted one week later.Birth Control Patch Like COCs, the patch, Xulane, contains the hormones estrogen and progestin. A new patch is applied by the user to the upper outer arm, back, buttocks, or abdomen once a week for three weeks, then no patch is worn for one week. The cycle is then repeated.
Which of these you choose, if any, may depend on your lifestyle, health history, age, whether and when you desire to have children, and possibly your insurance coverage. RELATED: What Are the Best and Worst Birth Control Options?
Some Types of Birth Control Pills May Improve Migraine
For some women with migraine, particularly menstrual migraine, taking birth control pills with estrogen can be a win-win because of the pills’ effect on hormone levels. Women often experience migraine symptoms when their estrogen levels change or drop, and the pills can help to even out those levels, according to the American Headache Society. A conventional pack of combination birth control pills contains between 21 and 24 pills that contain hormones and between four and seven placebo, or inactive, pills that contain no hormones. A woman generally bleeds, or has her period, during the days when she takes the inactive pills. Women with menstrual or menstrually related migraine often have success with certain COCs that have only two placebo days, versus other options that have four, five, or seven placebo days, says Levitt. “By using the pill that has fewer placebo days, we can keep the patient on more of a steady state with her estrogen level; this can help many people feel better, because they’re not having that horrible menstrual migraine week,” she says. But not all experts agree that birth control pills are off-limits to women who have migraine with aura. Recommendations released by the International Headache Society in 2000, for example, contain no specific guidelines not to use oral contraceptive pills in women who have migraine with aura, according to a 2018 review in the journal Stroke. According to Levitt, the mechanism of migraine is vasoconstriction (narrowing) in the arteries, mostly and in and around the brain. “If you have a tendency to form blood clots, you might have a higher incidence of stroke,” she says. However, the absolute risk of stroke is low: According to an article published in 2017 in Current Neurology and Neuroscience Reports, stroke related to migraine, called migrainous stroke, accounts for only 0.2 to 0.5 percent of all ischemic strokes. In the United States, that would mean about 2,000 to 4,000 out of the nearly 800,000 strokes that occur each year, according to CDC statistics. Nonetheless, “we want to have a conversation about the risk, even though it’s very small,” says Levitt.
Newer Birth Control Pills Carry Less Risk
Modern COCs have a lower dose of estrogen and carry less risk of stroke than older contraceptive formulations, according to the American College of Cardiology. Today, most combination birth control pills contain between 10 and 35 micrograms (mcg) of estrogen, according to the Mayo Clinic, while older formulations of birth control pills have as much as 50 mcg of estrogen. “We typically say that the lowest dose that does the best job for the patient is ideal, so I normally will recommend the lowest estrogen combination pill,” says Levitt. “There is a low-dose pill that contains 10 micrograms of estrogen, which is the lowest that it gets, and there’s no generic for that. The next one up is 20 micrograms.”
If Birth Control Causes Migraine Symptoms to Get Worse, Tell Your Doctor
There are instances where birth control may increase migraine symptoms, says Levitt. “This can happen at first, and then it levels off. I usually will have a patient circle back within three months of starting a pill. We check blood pressure and talk about how they feel and what their migraine attack frequency is,” she says. “If it is increasing, then I usually switch them off, or we’ll change methods to a non-estrogen. I don’t want anyone feeling worse,” Levitt says. Different people have different responses to changes in hormone levels, Levitt points out. “Menopause is a good example of that,” she adds. After menopause, the ovaries no longer produce much estrogen, but not all women with migraine respond the same way to that. A 2018 study published in Current Treatment Options in Neurology found that although about 24 percent of women had headache improvement with menopause, for approximately 36 percent, it worsened. In this study “headache” included migraine disease as well as other headache types. Speaking of birth control pill, Levitt says, “It’s relatively rare that migraine symptoms get worse with the combination pills.” If that happens or if a woman develops migraine symptoms for the first time after starting oral contraceptives, she should consider that a red flag and discuss it with her healthcare provider, according to the American Migraine Foundation.
Birth Control Options Without Estrogen
Some birth control pills and other hormonal contraceptives contain only progestin. Again, because women can respond to hormone fluctuations differently, these options could improve or worsen migraine. In cases where taking progestin-only pills causes amenorrhea (the absence of menstruation), headache and migraine often improve, according to a paper published in Reviews in Obstetrics & Gynecology. PPPs may not always suppress ovulation, however, and so estrogen fluctuation may occur, which has the potential to trigger migraine, according to the same paper. “Everyone is a little different,” says Levitt. “Some people will experience a little headache with hormones in general.” There are also non-oral birth control options such as IUDs, the birth control implant, or the monthly shot, all of which contain only progestin, no estrogen.
Migraine and Birth Control: Finding What Works for You
Because of the potential risks and benefits of the different types of birth control, women with migraine should work with their doctors to decide what is best for them, says Levitt. “There are several options. People just shouldn’t lump all hormonal contraception together under one umbrella,” she says. “Ask your doctor specific questions. Once you figure out plan A, it’s also a good idea to discuss what plan B and plan C might be,” says Levitt. Finding a doctor who can help you choose the right birth control is important for lots of reasons, including the possibility that it could help improve migraine symptoms, she says. “Some birth control pills can give you hormones back during certain points during your cycle,” Levitt says. “It can also be good for patients who are entering perimenopause [when estrogen levels tend to fluctuate] and menopause [when estrogen levels decline], because the migraine frequency and pain may intensify there, too.”
