Contraception - Birth Control

Summary: NuvaRing (vaginal ring)[used continuously] or Amethyst (continuous OCP) or Seasonique (extended cycle OCP) preferred in migraine without aura. Slynd progestin-only pill (POP) preferred for migraine with aura.

Contraception in Women with Migraine

CDC U.S. MEC 2024 framework • MEC = Medical Eligibility Criteria, a safety guide created by WHO and adapted by CDC (U.S. MEC) • migraine-focused preferences

Migraine WITHOUT aura • especially menstrual migraine

CHC (combined hormonal contraceptive) = MEC 2* (advantages outweigh risks)

Menstrual migraine benefit: continuous use suppresses cycling and avoids estrogen withdrawal. Ring, patch, or continuous oral CHC (combined hormonal contraceptive) can accomplish this.

Preferred estrogen-containing option for menstrual/hormone-related migraine:
Continuous etonogestrel/ethinyl estradiol vaginal ring (NuvaRing/generic) — replace every 3 weeks without a hormone-free interval.

Patch: NuvaRing is preferred but if rejected, second choice is Xulane continuously — change patch every 7 days, no patch-free week.
If ring and patch is declined LoSeasonique-type COC preferred: levonorgestrel 0.1 mg / ethinyl estradiol 20 µg daily. Continuous regimen: Take 1 active combination tablet daily continuously. Skip the 7 low-dose EE-only tablets at the end of each pack and immediately begin the active combination tablets of the next pack. Breakthrough bleeding/spotting is common initially. Alternative: Amethyst/generic (levonorgestrel 90 µg / ethinyl estradiol 20 µg), FDA-approved for continuous daily use with no hormone-free interval.

Taking topiramate (or an enzyme-inducing anticonvulsant)? The 15–20 µg EE options above may be less effective; see the interaction table below. If a COC is used, CDC specifies ≥30 µg EE. Because topiramate is teratogenic, an IUD, implant, or DMPA is often the better choice.

Migraine WITH aura; Migraine WITHOUT AURA if no menstrual migraine

WITH aura: CHC (combined hormonal contraceptive with estrogen) = MEC 4 — do not use

WITHOUT aura and no menstrual migraine: CDC still classifies CHC as MEC 2; the progestin-only and IUD options below are a practice preference here, not a CDC contraindication.

Avoid estrogen-containing pill, patch, and vaginal ring.

Preferred oral option: drospirenone 4 mg POP (Slynd) when an oral method is desired.

norethindrone or norgestrel POP (progestin-only pill) other than Slynd, such as Opill - available without prescription but Slynd preferred
LNG-IUD Mirena
etonogestrel implant Nexplanon
Depo-Provera depot medroxyprogesterone acetate (DMPA)
copper IUD

*CDC's migraine-without-aura CHC classification assumes no other major stroke-risk condition that independently changes eligibility; evaluate the whole patient.

Migraine Aura

Aura: A fully reversible focal neurologic symptom, usually visual, sensory, or speech/language, that typically develops gradually over ≥5 minutes and lasts 5–60 minutes. Typical visual aura includes an expanding scintillating scotoma, zig-zag/fortification pattern, or spreading visual-field defect.

Usually NOT aura: Nonspecific blurred vision, floaters, brief flashes/spots, photophobia, difficulty focusing, visual symptoms lasting only seconds, or generalized lightheadedness/dizziness. These should not automatically be labeled aura.

Common U.S. products & patient instructions

NuvaRing / EluRyng / generic
EPIC search: etonogestrel 0.12 mg/day + ethinyl estradiol 0.015 mg/day vaginal ring

For menstrual migraine suppression (continuous; off-label schedule): Insert 1 ring vaginally and leave in place for 21 days. Remove and immediately replace with a new ring; no ring-free interval. Dispense 4 rings/84 days (or 17 rings/year). Refills as appropriate.

Patient: Replace on the same day every 3 weeks. Spotting is common initially. Check periodically that the ring remains in place. If it comes out or replacement is delayed, follow the product missed-ring instructions and use backup contraception when indicated.

FDA labeling for NuvaRing/EluRyng is 21 days in + 7 days out. Immediate replacement every 21 days for menstrual suppression is an extended/continuous regimen and is off-label. Document the reason (avoid estrogen withdrawal/menstrual migraine).

Patch — NO aura

Xulane (norelgestromin/ethinyl estradiol)
EPIC search: norelgestromin 150 mcg/day + ethinyl estradiol 35 mcg/day transdermal patch

Apply 1 patch weekly for 3 consecutive weeks, then 1 patch-free week; repeat every 28 days.

For menstrual migraine suppression (continuous; off-label schedule): Apply 1 new patch every 7 days continuously; no patch-free week. Dispense 12 patches/84 days. Refills as appropriate.

Patient: Apply to clean, dry skin on abdomen, buttock, upper outer arm, or upper torso (not breast). Change on the same weekday. Do not cut. If detached or late, follow package instructions and use backup when indicated.

Xulane: contraindicated at BMI ≥30 kg/m²; labeling notes reduced effectiveness at higher body weight. Overall EE exposure is higher than with a typical 35-mcg EE oral contraceptive, and continuous (no patch-free week) use increases cumulative exposure further; FDA labeling is 3 weeks on + 1 week off, so continuous use is off-label. The ring is therefore preferred ahead of Xulane for a migraine-focused preference.

Twirla (levonorgestrel/ethinyl estradiol)
EPIC search: levonorgestrel 120 mcg/day + ethinyl estradiol 30 mcg/day transdermal system

Apply 1 patch weekly for 3 consecutive weeks, then 1 patch-free week; repeat every 28 days.

Patient: Apply to abdomen, buttock, or upper torso (not breast). Change every 7 days. Do not cut.

Caution: contraindicated at BMI ≥30 kg/m²; effectiveness is reduced at BMI 25 to <30 kg/m².

Preferred oral option when aura is present

Slynd (drospirenone 4 mg POP)
EPIC search: drospirenone 4 mg tablet

Take 1 tablet by mouth daily. Take 24 active tablets followed by 4 inactive tablets; start the next pack immediately after finishing the pack. Dispense 84 tablets (3 packs). Refills as appropriate.

Patient: Take at about the same time daily. If 1 active pill is missed, take it when remembered and continue—no backup required. If ≥2 active pills are missed, take the last missed pill, continue daily, and use nonhormonal backup for 7 days. Expect possible irregular bleeding.

Before ordering: review renal/adrenal/hepatic disease and medications that increase potassium because drospirenone has antimineralocorticoid activity.

Errin / Camila / Nora-BE / generic norethindrone POP
EPIC search: norethindrone 0.35 mg tablet

Take 1 tablet by mouth at the same time every day continuously. No pill-free interval. Dispense 84 tablets. Refills as appropriate.

Patient: Timing is strict. A pill >3 hours late is considered missed; take it as soon as remembered and use backup contraception for the next 48 hours. Continue through bleeding/spotting.

Opill (norgestrel 0.075 mg POP; OTC)
EPIC/search if documenting: norgestrel 0.075 mg tablet

Take 1 tablet by mouth at the same time every day continuously. No pill-free interval.

Patient: Start any day; use barrier backup for the first 48 hours. If >3 hours late or a pill is missed, take one as soon as remembered and use backup for 48 hours.

LARC Long-Acting Reversible Contraception / injection (aura or no aura)

LNG-IUDs: Mirena, Liletta, Kyleena • implant: Nexplanon • injection: Depo-Provera CI • copper IUD: Paragard.
EPIC workflow: these are generally ordered through the contraception/family-planning procedure workflow rather than as a routine outpatient pharmacy prescription. Select the exact device/injection supported by your local preference list and follow the institution's insertion/administration order set.

Migraine medication interaction check

Medication	What matters	Practical contraception approach
Topiramate	CDC groups topiramate with anticonvulsants that can reduce effectiveness of CHCs and certain progestin-only methods. CHC = MEC 3 for the interaction.	Prefer a method not dependent on affected hormone levels for long-term therapy (e.g., copper IUD or DMPA). LNG-IUD is not meaningfully affected by enzyme induction. If a COC is chosen, CDC specifies ≥30 µg EE. Evidence for ring/patch interactions is less certain.
Carbamazepine, oxcarbazepine, phenytoin, phenobarbital/barbiturates, primidone	Enzyme induction can reduce hormonal contraceptive effectiveness.	Prefer copper IUD, LNG-IUD, or DMPA (MEC 1). Implant is MEC 2 (acceptable; some reduction in levels possible). Avoid relying on POP or CHC (MEC 3).
Lamotrigine monotherapy	Estrogen-containing COCs can substantially lower lamotrigine concentrations; levels can rise during hormone-free intervals.	Avoid creating large estrogen cycling when seizure/mood control depends on stable lamotrigine exposure; coordinate dosing/monitoring when CHC is used. Progestin-only or IUD methods simplify this interaction.

Important: do not reduce the topiramate issue to a ≥200 mg/day cutoff in the clinic guide. The CDC MEC recommendation is drug-based; dose-dependent PK evidence can inform individual counseling but does not replace the MEC classification.

Before prescribing estrogen

Confirm aura.
Check blood pressure and smoking.
Review VTE/stroke history, thrombophilia and other vascular risks.
Review migraine drugs for contraceptive interactions.
New focal neurologic symptoms or a marked headache-pattern change warrants reassessment.

Primary references

CDC U.S. Medical Eligibility Criteria for Contraceptive Use, 2024; CDC U.S. Selected Practice Recommendations, 2024; current FDA/DailyMed labeling for NuvaRing/EluRyng, Xulane, Twirla, Slynd, norethindrone POPs, and Opill.

Estrogen-progestin contraceptives - Only for Migraine Without Aura

Factor	NuvaRing	COCPs - Amethyst (Continuous Use) and Seasonique (Extended Cycle)
Hormonal Stability	Provides steady hormone release but requires consistent replacement.	Eliminates hormone-free intervals with continuous use.
Ease of Use	Inserted once every three weeks; more forgiving for missed replacements.	Requires daily adherence for effectiveness.
Estrogen Withdrawal	Can be used continuously to avoid withdrawal.	Designed for continuous use to prevent withdrawal.

Continuous or Extended Cycle OCPs - Amethyst vs. Seasonique

Feature	Amethyst (Continuous Use)	Seasonique (Extended Cycle)
Mechanism	Provides a steady level of hormones with no placebo pills, eliminating menstrual periods entirely.	Reduces the number of periods to four per year, with 84 days of active pills followed by 7 days of low-dose estrogen.
Advantages for Menstrual Migraine	Eliminates hormonal fluctuations: Since there are no hormone-free days, it minimizes the risk of estrogen withdrawal, a key trigger for menstrual migraines. Suitable for patients who want to completely avoid periods and their associated symptoms, including migraines.	Reduces hormonal withdrawal effects: The 7 days of low-dose estrogen in place of placebo pills can blunt the estrogen drop, a common migraine trigger. Ideal for patients who prefer fewer but predictable periods.
Potential Drawbacks	Breakthrough spotting or irregular bleeding may occur, especially in the first few months, which could still be a migraine trigger for some patients. Requires a strong commitment to taking the pill daily without breaks.	Some patients may still experience migraines during the low-estrogen phase, albeit less severe than during a complete hormone withdrawal. Periods are less frequent, but still occur, which may not be ideal for patients who want to avoid migraines entirely.

Considerations

Individuals with debilitating MM (menstrual migraine) or MRM (menstrual related migraine) who do not have aura can be offered hormonal therapy with estrogen-progestin contraceptives to suppress their physiologic cycling of estrogen and progesterone Options for treatment:

Continuous dosing (ie, without placebo week) of estrogen-progestin oral pills
Continuous dosing with Nuva Ring vaginal rings (transdermal contraceptive patches are not advised for continuous dosing regimens).
Use of estrogen-progestin oral pills with ultralow (10 to 15 micrograms) or low doses (20 to 30 micrograms).
Use of extended-cycle preparations that reduce the number of withdrawal bleeds to four per year.

Hormonal Contraceptive Vaginal Rings – Continuous Use

NuvaRing, EluRyng (generic), Haloette (generic) (ENG/EE)

Etonogestrel and ethinyl estradiol ring (ENG/EE). There is an immediate increase in serum hormonal concentration after insertion with a slow decrease over the cycle. The concentration of EE is lower with the ENG/EE vaginal ring compared with other combined hormonal contraceptives
Common Adverse Reactions (≥ 2%): headache (including migraine) 11.2%
I can prescribe. Affordable Care Act (Obamacare) -- most insurance plans must cover all methods of birth control with little or no cost, including the ring.
Extended ring regimen up to 1 year: prior ENG/EE ring is removed and a new ring is immediately inserted every three weeks.

Annovera (SA/EE)

Segesterone and ethinyl estradiol ring — The one-year reusable segesterone acetate/ethinyl estradiol (SA/EE). The median Tmax of both hormones is approximately 2 hours after vaginal insertion; concentrations become more constant approximately 96 hours after insertion. Does not require refrigeration. Not orally active, which may appeal to lactating people who want to avoid exposing their infants to progestin. Annual. Comfortable, squishy. Available online (BlinkRx).
Common Adverse Reactions: Headache, including migraine 38.6%
Because incidence of headache in clinical trials was so high (greater than OCPs), I believe NuvaRing is a better choice.

Continuous use for menstrual suppression

Data supporting continuous ring use for menstrual suppression come from studies of the ENG/EE ring. People who desire fewer days of withdrawal bleeding and are willing to tolerate some spotting can safely use an extended ring regimen whereby the prior ENG/EE ring is removed and a new ring is immediately inserted every three weeks, which omits the hormone-free week and resultant withdrawal bleeding for up to one year. Extended use is effective and does not worsen bothersome side effects, except for unscheduled bleeding. Data supporting continuous use of the SA/EE ring are not yet available, but continuous use (ie, no time break between yearly ring removal and replacement) is clinically reasonable. As with the ENG/EE ring, patients are counseled about possible increase in unscheduled bleeding.

Feature	NuvaRing	Annovera
Hormones	Etonogestrel (progestin) and ethinyl estradiol (estrogen)	Segesterone acetate (progestin) and ethinyl estradiol (estrogen)
Usage Duration	Monthly: Inserted for 3 weeks, removed for 1 week, then replaced	Year-long: Inserted for 3 weeks, removed for 1 week, and reused for 13 cycles
Reusability	Single-use	Reusable for one year
Storage Requirements	Requires refrigeration before dispensing; can be stored at room temperature for up to 4 months	No refrigeration needed; stored at room temperature throughout its lifespan
Cost	Lower upfront cost; requires monthly refills	Higher upfront cost; lasts a full year
Convenience	Requires monthly replacement and prescription refill	Low-maintenance; no need for monthly replacement
Eco-Friendliness	Generates more waste (monthly replacement)	Less waste (reusable for a year)
Incidence of Headache	Approximately 9.8%	Approximately 38.6%, including migraines
Effectiveness	Similar efficacy; less than 1% pregnancy rate with typical use	Similar efficacy; less than 1% pregnancy rate with typical use
Side Effects	Nausea, headaches, breast tenderness, mood changes, vaginal irritation	Nausea, headaches (higher rate), breast tenderness, mood changes, vaginal irritation

Birth Control Patche (Transdermal Systems) - Not Recommended for Migraine Because Dose of Estrogen is Higher

Xulane

norelgestromin and ethinyl estradiol patch (Mylan Pharmaceuticals Inc.)
(Generic of Ortho Evra, which has been discontinued.)
Transdermal system: 150 mcg/day norelgestromin and 35 mcg/day ethinyl estradiol
Xulane uses a 28-day (4-week) cycle. Apply a new patch to the upper outer arm, abdomen, buttock or back each week for 3 weeks (21 total days). Week 4 is patch-free. Apply each new patch on the same day of the week. Wear only one patch at a time.
Contraindicated: headaches with focal neurological symptoms or have migraine headaches with aura; women over age 35 with any migraine headaches
Pregnancy rate in women aged 18 to 35 years was 1.07 (95% CI: 0.60-1.76) per 100 woman-years

Mean Serum Concentration-Time Profiles of EE Following Once-Daily Administration of an Oral Contraceptive for Two Cycles or Application of Norelgestromin and Ethinyl Estradiol Trans dermal System for Two Cycles to the Buttock in Healthy Female Volunteers . [Oral contraceptive: Cycle 2, Days 15 to 21, Norelgestromin and Ethinyl Estradiol Transdermal System: Cycle 2, Week 3] 168 hours = 7 days

Twirla (levonorgestrel & ethinyl estradiol) transdermal system

Low dose; higher risk of pregnancy than Xulane!

Second transdermal contraceptive patch available in the U.S.
Daily hormone exposure is similar to that with oral contraceptives containing 30 mcg of ethinyl estradiol and 120 mcg of levonorgestrel
Low dose; not clear if this provides reduced risk venous thromboembolism (VTE), which is one of the most significant safety concerns associated with combined hormonal contraceptive use
Pearl Index (PI) measures the pregnancy rate per 100 women-years of drug exposure. Twirla's PI was 5.83, which exceeds Xulane. Obese women (BMI ≥30kg/m2) = 8.64; non-obese women 4.34.
Contraindicated in women with a BMI >30 kg/m2.
Contraindicated in women who have headaches with focal neurological symptoms or have migraine headaches with aura, and in women over age 35 years who have migraine headaches with or without aura.

Ortho Evra was discontinued in the U.S. after the FDA approved Xulane, a generic hormonal birth control patch, in 2014. Xulane delivers the same high levels of estrogen as the Ortho Evra patch.

Stroke Risk

Risk of ischemic stroke in women with migraine is about 2 times higher than that of women without migraine, driven
largely by increased risk in the subgroup of women who have migraine with aura.
An association between migraine and an approximately 1.5 times increased risk of hemorrhagic stroke has also been shown.
Greatest increase in stroke risk is seen in women with migraine in their reproductive years, who are under the age of 45, and who otherwise have few stroke risk factors. The elevation in risk of stroke is amplified by other risk factors, particularly smoking.
Combined hormonal contraceptives with low estrogen probably have reduced stroke risk (low estrogen OCPs: 20-25 µg ethinyl estradiol; average 35 µg; some as low as 10 µg)
Absolute risk of stroke in reproductive-aged women is low (3.56 per 100,000 women of reproductive age per year)

Relative increased ischemic stroke risk about 3-fold

20 µg EE 1.6 (not clear that risk is increased)
30-49 µg EE 2.0 (no clear that risk is increased
>49 µg EE 2.4 (clear increased stroke risk)

One study differentiated risk by presence or absence of migraine aura and found an increased risk in the migraine with aura population (OR 6.1 in migraine with aura vs 1.8 migraine without aura group).

Sheikh HU, Pavlovic J, Loder E, Burch R. Risk of Stroke Associated With Use of Estrogen Containing Contraceptives in Women With Migraine: A Systematic Review. Headache. 2018 Jan;58(1):5-21.

Progestin-only Pill (POP) - For Patients with Migraine with Aura

Nora-BE, Camila and Errin are interchangeable generics marketed under different names. Slynd uses the newer progestin drospirenone with anti-androgenic and anti-mineralocorticoid activity. It may be more expensive.

Name	Active Ingredient	Availability	Notes
Opill	0.075 mg of norgestrel	Over-the-Counter (OTC)	First OTC progestin-only contraceptive, available since 2023.
Slynd	4 mg of drospirenone	Prescription	Newer option with a 24-active plus 4-inert pill regimen.
Nora-BE	0.35 mg of norethindrone	Prescription	Traditional progestin-only contraceptive.
Camila	0.35 mg of norethindrone	Prescription	Another traditional progestin-only option.
Errin	0.35 mg of norethindrone	Prescription	Part of the traditional progestin-only contraceptives.

Feature	Slynd (Drospirenone)	Other POPs (Norethindrone)
Progestin Type	Drospirenone	Norethindrone
Regimen	24 active + 4 placebo	Continuous active (28 pills)
Missed Pill Window	24 hours	3 hours
Androgenic Effects	Anti-androgenic, reduces acne	Androgenic, may exacerbate acne
Fluid Retention	Reduces bloating and retention	No diuretic effect
Suitability	Flexible use, special populations	Strict timing required

Impact of Drospirenone (Slynd):

Anti-Androgenic Effects:
- May improve conditions like acne or hirsutism (excess hair growth).
- Less likely to exacerbate androgen-related side effects, such as oily skin or hair loss.
Anti-Mineralocorticoid Effects:
- Reduces fluid retention and bloating, offering potential benefits for individuals sensitive to water retention.
- May slightly lower blood pressure.

Other advantages of Slynd Versus Other POPs:

Missed Pill Window:

Slynd: Offers a 24-hour missed pill window, meaning contraceptive protection is maintained even if a dose is taken up to 24 hours late. This flexibility can reduce missed doses and improve real-world efficacy.
Other POPs: Require doses to be taken within a 3-hour window daily, making them less forgiving and more prone to user error.

Ovulation Suppression:

Slynd: Suppresses ovulation more consistently (~99% of cycles), akin to combination birth control pills. This adds a layer of protection beyond the cervical mucus-thickening mechanism.
Other POPs: Do not consistently suppress ovulation and rely more heavily on thickened cervical mucus and endometrial changes for contraception.