A 28-year-old woman from Delhi presents to the gynecology clinic requesting contraception. She has a history of migraine with aura, which occurs 2–3 times per month. Her blood pressure is 118/76 mmHg, and general examination is unremarkable. She is a non-smoker and has no family history of thromboembolism. Which of the following is the most appropriate contraceptive choice for her?

Explanation

## Clinical Context This patient has **migraine with aura**, which is a critical contraindication to estrogen-containing contraceptives due to the increased risk of ischemic stroke. ## Why Copper IUD is Correct **Key Point:** Migraine with aura is a WHO category 4 contraindication (absolute contraindication) to combined hormonal contraceptives (CHCs) containing estrogen, regardless of dose or formulation. The copper intrauterine device (Cu-IUD) is: - Non-hormonal and therefore safe in migraine with aura - Highly effective (>99% efficacy) - Long-acting reversible contraception (LARC) - No systemic absorption of hormones - Suitable for nulliparous and multiparous women ## Mechanism of Risk in Migraine with Aura Estrogen increases thrombotic risk through: 1. Increased hepatic synthesis of clotting factors (II, VII, X) 2. Increased platelet aggregability 3. Migraine with aura is associated with cortical spreading depression and transient cerebral ischemia 4. Combination of estrogen + migraine aura = synergistic stroke risk (relative risk ~8–10 fold) ## Alternative Options | Contraceptive | Suitability in Migraine with Aura | Reason | |---|---|---| | **Combined oral contraceptive** | **WHO Cat 4 (Contraindicated)** | Estrogen increases stroke risk | | **Progestin-only pill** | WHO Cat 2 (Acceptable) | No estrogen; however, lower efficacy (91% typical use) | | **Copper IUD** | **WHO Cat 1 (Recommended)** | Non-hormonal; excellent efficacy | | **Transdermal estrogen patch** | **WHO Cat 4 (Contraindicated)** | Still contains estrogen; same risk as oral | **High-Yield:** The WHO Medical Eligibility Criteria (MEC) classifies migraine with aura + estrogen as Category 4 (unacceptable health risk). Progestin-only methods (pill, injection, implant) are Category 2 (acceptable with caution), but Cu-IUD is the gold standard due to superior efficacy and no hormonal side effects. **Clinical Pearl:** Always ask about **aura** specifically. Migraine without aura is only WHO Cat 2 with estrogen; migraine with aura is Cat 4. Many patients are unaware whether they experience aura (visual symptoms, paresthesia, speech disturbance 20–60 min before headache).