Contraceptive Choices in Migraine

Which of the following best describes the use of contraception for a 26 year old woman who has migraine without aura, usually three episodes per month controlled with high dose ibuprofen who is otherwise well states. "I want to get on some birth control that's really reliable for the next three years while I'm in graduate school."

A. All combined hormonal contraceptive forms are contraindicated with any type of migraine.

B. Combined hormonal contraception is acceptable for use in this clinical situation.

C. Progestin-only contraceptive methods should be avoided in migraine with or without aura due to the increased risk for elevated blood pressure.

D. Barrier contraceptive methods are preferred in this situation.

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Transcript

Voiceover: Welcome to NP Certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Expert Fitzgerald faculty clinicians share their knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer. So, if you're ready, let's jump right in. 

Margaret Fitzgerald: Which of the following best describes the use of contraception for a 26 year old woman who has migraine without aura, usually three episodes per month controlled with high dose ibuprofen who is otherwise well states. "I want to get on some birth control that's really reliable for the next three years while I'm in graduate school." 

A. All combined hormonal contraceptive forms are contraindicated with any type of migraine. 

B. Combined hormonal contraception is acceptable for use in this clinical situation. 

C. Progestin-only contraceptive methods should be avoided in migraine with or without aura due to the increased risk for elevated blood pressure. 

D. Barrier contraceptive methods are preferred in this situation. 

The correct answer is B. Combined hormonal contraception is acceptable for use in this clinical situation. 

Where should you start? First determine what kind of a question this is. Given that the focus of the question is on contraceptive prescribing or contraceptive advice, this is a plan/intervention question. 

First, some background information. Even with the availability of numerous methods of highly reliable contraception, nearly half of the pregnancies in the United States are unplanned. When it comes to contraceptive choices, the focus of this question, many factors need to be considered. As with any other medication, safety and efficacy are major concerns. The US medical eligibility criteria for contraception use abbreviated USMEC capital M capital E capital C usually just referred to as MEC includes recommendations for the use of specific contraceptive methods for individuals with certain characteristics or health issues. When counseling about contraceptive method choice, USMEC can be used to identify safe and effective contraceptive choices above and beyond barrier methods for nearly all persons. They even have information about barrier methods in there. 

The USMEC categories are as follows:

Category one, no restrictions on the use of this contraceptive method. 

Category two, advantages outweigh risk with one obvious advantage being avoiding pregnancy. 

Category three, exercise caution. Theoretical or proven risks usually outweigh benefit. 

Category four, the use of this contraceptive method represents an unacceptable health risk. 

As I've mentioned on many other podcasts, always look for what's special or specific in the clinical scenario presented in the question. Again, migraine without aura is a special consideration here, but there's another special consideration in here that cannot be ignored. One more time. Every word in a question is important. And what does she say? I'm going to grad school. I don't want to get pregnant for the next 3 years. I really don't want to get pregnant while I'm in grad school.

This might ring true to some people listening to this podcast because you were trying to plan your family around going to graduate school, going to nursing school, whatever it was. But in any event, you can't just focus in on the migraine and ignore that part. So, in other words, there are two really special things that we need to consider here. So, we're looking for a contraceptive choice that's okay to use with migraine with without aura and is highly reliable. 

In this question, of course, the correct answer is combined hormonal contraception. usually abbreviated CHC and CHC's achieve contraceptive effect via progestin and estrogen components. This combination works primarily through suppression suppressing ovulation. It has some additional um features as well. 

With appropriate use, CHC usually results in fewer than one pregnancy per 100 women with perfect use. In addition, CHC's can offer contraceptive method that's easily initiated, become effective either immediately or certainly no more than one week after starting depending on the method and the timing during the menstrual cycle. 

By the way, that's another topic, another podcast on stopping starting contraceptive methods. 

Now, what's another special part here? the migraine without aura. But do not think that migraine without aura is the same as migraine with aura because in people with migraine with aura, the use of combined hormonal contraception is associated with higher risk for ischemic stroke than in people without headache, without migraine or even migraine without aura. And, migraine with aura at baseline, even without CHC, increases stroke risk. And it's actually the estrogenic, not the progestin component of CHC that furthers increase this risk. To be sure, the stroke risk is low. But did I mention it's stroke? It is not an upset stomach or a skin rash or something that maybe a person could work around. It is a stroke. And so one more time though, stroke risk is not increased with CHC use in migraine without aura. 

So with that as background information, let's go back to the question. Which of the following best describes the use of contraception for a 28-year-old woman who has migraine without aura, usually three episodes per month, controlled with high doses ibuprofen, who uh is otherwise well. She states, "I want to get on some birth control that is really reliable for the next three years while I'm in graduate school." A. All combined hormonal contraceptive forms are contraindicated with any type of migraine. Well, clearly this is incorrect. Well, migraine with aura is a MEC category 4. Do not use because of the slightly observed increased risk in stroke. This person has migraine without aura. So don't look at migraine and say okay never never CHC. You have to differentiate is migraine with or without aura 80% of people with migraine have migraine without aura. Okay. In addition, what um keep in mind that progestin only contraceptive forms such as implant, progestin-only pills, injection, and leave in containing IUD can be used in the presence of migraine whether it's with or without aura MEC one category. 

B combined hormonal contraception is acceptable for use in this clinical scenario. This is true. This is the correct answer. And just as a reminder, combined hormonal contraception, the most commonly used form is what would what is commonly called birth control pills, but it also includes the uh contraceptive patch in vaginal ring. Uh given that she reports migraine without aura, the stroke risk is not increased with the use of the estrogen progestin combination. in this contraceptive method. Also, we cannot ignore the fact that she is asking for a highly reliable form of contraception. We know she will get that from the consistent use of a CHC. 

Option C, progestin-only contraceptive method should be avoided in migraine with or without aura due to the increased risk for elevated blood pressure. This is incorrect. Progestin-only contraceptives can be safely used in migraine whether it's with or without aura. And there's truly regardless of the clinical scenario there is very little meaningful increase in blood pressure with any form of a progestin based contraceptive method. Okay. Indeed, I prescribe progestin only methods, particularly the progestin-only pill um quite often in women seeking contraception who have a variety of different health issues like high blood pressure, type 2 diabetes, dyslipidemia, particularly to bridge them to a more effective and easier to use contraceptive form um like a progestin implant or leave in containing IUD. 

Take a look at the CDC contraceptive guidelines. In almost any clinical scenario, progestin-only methods are MEC one with a very occasional MEC two.

However, remember progestin-only pills do carry a fairly high contraceptive failure rate compared to the CHC, possibly as high as 13%. 

Option D, barrier contraceptive methods are preferred in this situation. Well, barrier contraceptive methods are not contraindicated in any form of migraine. This isn't a great answer. What is the patient saying? I don't want to get pregnant for the next three years while I'm in grad school. Well, there's variability among methods and often this is you user dependent. The uh range of barrier failure is about 13 to 27%. This is a good example of an answer that's technically not incorrect, but it's not a great choice. 

Key takeaway, the CDC MEC for contraceptive use is a valuable clinical tool. It's widely available in free of charge, great app, it's on my phone, I use it all the time. If you don't have it on your phone now or whatever device you use in in practice, please get it. You can look at the CDC's website for further information or just check most major app stores. you will be able to find it.

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