Combined hormonal contraceptives and migraine: An update on the evidence

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FIGURE 1
Serum estradiol levels in the natural menstrual cycle (top) and with high-dose cyclic and low-dose continuous combined oral contraceptives (bottom).

TABLE 1

Combined hormonal contraceptives that can help prevent menstrual-related migraine

Brand name	Generic alternatives	Dose	Clinical pearls
Continuous formulations
Lybrel^a	Ashlyna 28 Amethyst 28^a	Ethinyl estradiol 20 µg and levonorgestrel 0.09 mg once daily for 365 days/year	Can substitute any generic 20-µg ethinyl estradiol pill and continue without placebo pills
NuvaRing	None (though many insurance plans cover it)	Vaginal ring Delivers ethinyl estradiol 15 µg and etonogestrel 0.12 mg daily Can be inserted once every 4 weeks to be used in a continuous fashion	Women who are sensitive to the drop in estrogen level in the last week may need to replace the ring every 3 weeks

Extended formulations
LoSeasonique	Amethia Lo Camrese Lo	Ethinyl estradiol 20 µg and levonorgestrel 0.1 mg for 84 days, then ethinyl estradiol 10 µg for 7 days	If a 30-µg ethinyl estradiol pill is used, will need to take it continuously to avoid triggering migraine

Monthly formulations
Lo Loestrin 1/10	None	Ethinyl estradiol 10 µg and norethindrone 1 mg for 24 days, then ethinyl estradiol 10 µg for 2 days, then placebo for 2 days	Ultra-low doses may be associated with increased breakthrough bleeding; the bleeding can improve over time
Natazia	None	Estradiol valerate doses gradually decrease from 3 to 2 to 1 mg; dienogest dose increases from 2 to 3 mg	This pill pack has a different missed-pill algorithm; refer to package insert for specific instructions