A 28-year-old woman from Delhi presents to the gynaecology clinic seeking contraception. She has a history of migraine with aura, which is well-controlled on topiramate. Her menarche was at age 13, and she has regular 28-day cycles. She is a non-smoker and has no family history of thrombosis. On examination, BP is 118/76 mmHg, BMI 22 kg/m². She is counselled about various contraceptive options. Which of the following is the most appropriate choice for this patient?

Explanation

## Clinical Reasoning This patient has **migraine with aura**, which is an absolute contraindication to combined oral contraceptives (COCs) due to the significantly increased risk of ischaemic stroke. The WHO Medical Eligibility Criteria (MEC) classify COCs as Category 4 (unacceptable health risk) in women with migraine with aura. ### Why Cu-IUD is the Best Choice **Key Point:** Copper intrauterine devices are non-hormonal, highly effective (>99%), and have no systemic drug interactions or vascular complications. They are ideal for women with contraindications to hormonal contraception. - No oestrogen or progestin exposure → no thrombotic or stroke risk - Efficacy unaffected by topiramate (no enzyme induction interaction) - Long-acting reversible contraception (LARC) with 10-year lifespan - Can be inserted immediately and removed at any time - No absolute contraindications in this patient (no copper allergy, no Wilson's disease, no active pelvic infection) ### Why Other Options Are Unsuitable | Option | Problem | |--------|----------| | **COC (30 µg EE + LNG)** | Migraine with aura = WHO Category 4; increased stroke risk due to oestrogen-induced hypercoagulability and endothelial dysfunction | | **Progestin-only pill (POP)** | While safer than COCs in migraine with aura (WHO Category 2), less reliable (91–99% efficacy vs. 99%+ for Cu-IUD); requires strict timing; norethisterone has androgenic effects | | **DMPA 150 mg IM** | Acceptable (WHO Category 2) but less ideal than Cu-IUD; causes irregular bleeding, weight gain, and delayed return to fertility; requires quarterly injections | ### Mechanism of Stroke Risk in Migraine with Aura **Clinical Pearl:** Migraine with aura is associated with cortical spreading depression and transient cerebral hypoperfusion. Combined oestrogens increase platelet aggregability, reduce fibrinolysis, and promote a prothrombotic state. Together, these factors significantly elevate ischaemic stroke risk—approximately 4–8 fold in women taking COCs with migraine with aura. **High-Yield:** WHO MEC 2015 (reaffirmed 2023) classifies: - **Migraine without aura** → COC = Category 2 (advantages outweigh risks) - **Migraine with aura** → COC = Category 4 (unacceptable risk) [cite:WHO Medical Eligibility Criteria 2015; KD Tripathi 8e Ch 64]