Mirena and Migraines: Unraveling the Headaches Mystery!

Mirena and Migraines: Is there any link or association? Does Mirena cause migraine or does it make your migraine worse? Does Mirena help migraines?

There are so many questions migraine sufferers or Mirena users search for when they plan Mirena insertion for the long-term prevention of pregnancy.

This post is about Mirena and Migraines. We’ll try to cover almost every aspect of the topic here.

What is Mirena IUD:

Mirena IUD is a medicated device that is inserted into the uterus of an adult female. This device is a depot of Levonorgestrel, a progestin hormone, that is slowly released over a period of up to five years.

Thus, once inserted, it can prevent pregnancy for up to five years. Mirena IUD is also sometimes used to treat heavy menstrual bleeding and endometrial hyperplasia.

Levonorgestrel is also available as oral tablets and used as an “emergency contraceptive” to prevent pregnancy after unprotected sex if used within 72 hours. It is the same medicine as “morning after pill” and “Plan B“.

Mirena and Migraines with Aura/ Without Aura?

Mirena IUD releases Levonorgestrel which is basically a progesterone hormone. Studies have associated Migraine headaches with most contraceptives.

However, estrogen-containing oral contraceptives and combined hormonal contraceptives (CHC) which contain both estrogens and progestins are more strongly associated with migraine headaches than progestin-only contraceptives.

Thus, the link between Mirena and Migraines is not very strong. In fact, Mirena IUD may be preferred by women who have headaches when they take combined oral hormonal contraceptives.

In addition, Mirena IUD is less likely to be associated with strokes, DVTs (deep vein thrombosis), or hypercoagulable states,

• Does Mirena Cause Headaches?

Yes. Migraine headache has been reported in 16.3% of women using Mirena. Migraine headaches are the second most common side effect of Mirena after gynecological and pelvic side effects.

Mirena delivers Levonorgestrel at a rate of 20 mcg per day for up to 5 years. Levonorgestrel is a progestin.

Compared to Estrogen-only or CHC (combined hormonal contraceptive) pills, the risk of migraine headaches is much less.

In fact, migraine with aura is a contraindication to combined estrogen and progestin-containing hormonal contraceptives.

The WHO and ACOG guidelines recommend avoiding CHC even in women with migraine without aura if they are 35 years of age or older, smokers, and have additional risk factors such as obesity, high cholesterol, and a history of stroke [Ref].

Mirena is not contraindicated and is rather a safer alternative to CHC in women who have migraine.

However, the manufacturer recommends removing Mirena if the woman experiences severe headaches or migraine headaches after Mirena insertion [Ref].

• Does Mirena IUD help with menstrual migraines?

Menstrual migraine is a subset of migraine headaches that occur in menstruating women.

It starts two days before the onset of periods and continues for up to the third day of the menstrual cycle.

In addition, for a headache to be labeled as a menstrual migraine, it should occur in two-thirds of the menstrual cycle.

Menstrual migraines are thought to occur primarily as a result of estrogen withdrawal. Hence estrogen replacement and not progestin such as Levonorgestrel or Mirena, are indicated in the treatment of Menstrual Migraines.

It is important to understand that estrogen replacement is considered only after first-line therapies such as Mefenamic acid, other NSAIDs, and Triptans (Sumatriptan and Rizatriptan) fail to relieve the headaches.

So, Mirena and other progestin-only contraceptive devices and pills have not been studied in the treatment of menstrual migraines and may not help women with menstrual migraines (at least theoretically).

Progestins (Mirena and others), however, do have some pain-modulating effects because of their effect on the GABA receptors.

Studies need to be done to evaluate the role of Progestins in women with menstrual migraines [Ref].

Lastly, since Mirena suppresses menstruation, it is likely that women may get complete relief from menstrual migraines as they are no longer menstruating and there are little monthly variations in their hormones.

• Is Mirena Safe for Migraine Sufferers?

Mirena is a safer alternative to estrogen-only and combined estrogen-progesterone hormonal contraceptive pills in women with migraine headaches.

But, Mirena is not totally safe for migraine sufferers. In FDA-prescription labeling, the risk of migraine with Mirena use is estimated to be about 16.3% [Ref].

Mirena is not contraindicated in women with migraines, unlike CHC (combined hormonal contraceptives) which is absolutely contraindicated in women with Migraine headaches with aura.

Estrogens and CHC in women with migraine with aura increased the risk of strokes.

Mirena is also a safer alternative to CHC (oral contraceptives) in women who have migraine without aura and are 35 years of age or older, are smokers, have a history of stroke, and have high cholesterol levels.

• Will Mirena’s headaches go away on their own?

It depends. If you have a feeling of a foreign body in your uterus and are feeling discomfort and persistent pain that is causing your headache, then YES! The headaches will go away on their own as you get used to Mirena and your body starts accepting it.

However, if you have developed headaches after inserting Mirena because of hormonal imbalances, it may take you a lot of time, typically up to three months for your headaches to go away.

Mirena may relieve menstrual migraines completely once women stop menstruating.

If your headaches are severe or you have noticed atypical features such as weakness of the limbs, you may need to remove them straight away.

• Mirena and Migraines/ Headaches: When should you worry?

Mild or transient headache that lasts for a few hours and improves spontaneously or with OTC medications such as Tylenol, Advil, or low-dose Naproxen is common and nothing to worry about.

However, the following symptoms may need a consultation with a Neurophysician or a gynecologist regarding the removal of the IUD:

• Headache that is associated with visual loss, double vision, or blurred vision
• Headache that is associated with focal neurological deficits such as arm or leg weakness
• Severe headache that is not responding to first-line medications
• Severe headache that lasts for more than 24 to 48 hours.

Because there is an increased risk of stroke in patients who have migraine with aura, the onset of a new onset migraine with aura or a worsening of such symptoms may prompt the removal of the Mirena IUD.

• How to treat Mirena Migraines and Headaches?

There is no specific treatment for Mirena-induced headaches and migraines. Except in severe cases and those not responding to the treatment when removal of the IUD may be advised as a treatment option.

Mirena headaches and migraines can be treated with OTC medicines such as Tylenol, Advil, and Aleve.

Women who do not respond to the first-line OTC medicines may need Sumatriptan (Imitrex), Rizatriptan (Maxalt), Zolmitriptan (Zomig), and CGRP inhibitors like Nurtec and Ubrelvy.

• What is the best birth control for migraine sufferers and migraine with aura?

Migraine with aura is a risk factor for stroke, especially in women who are on hormonal contraceptives.

Contraceptive pills and devices that contain estrogens are contraindicated in women who have migraine with aura.

Progestin-containing pills such as the “morning after pill”, “plan B”, and “emergency contraceptive pills” are safer to use in women with migraine with aura.

Similarly, progestin-containing devices such as Mirena and injections such as Depo-Provera are also safer than CHC (combined hormonal contraceptives).

Here is a table listing all the progesterone-containing hormonal contraceptives that are relatively safer in women with migraines compared to estrogen-containing hormonal contraceptives:

Among the above progestin-containing hormonal contraceptives, Etonogestrel is third-generation progesterone and is superior to all the other progestin-containing contraceptives mentioned in the table which are second-generation progestins.

However, the safest birth control methods are barrier methods although these methods may not be very effective.

• What is the best IUD for migraine sufferers?

Now that we know, that progesterone-containing hormonal contraceptives are safer than estrogen-containing and combined hormonal contraceptives, what is the best IUD device for migraine sufferers?

We have the following hormonal IUDs or implants available:

Etonogestrel Contraceptive Implants

• Implanon
• Nexplanon

Levonorgestrel Hormonal Intrauterine Devices (IUDs)

• Mirena
• Skyla
• Kyleena

Implanon and Nexplanon are 3rd generation progestins and compared to Mirena, Skyla, and Kyleena, these implants are much safer and equally effective. However, when we talk about headaches, the difference is probably minimal.

Implanon and Nexplanon are subdermal implants that are placed in the skin of the arm. These implants are effective for up to 3 years after placement while Mirena is effective for up to 5 years.

In the FDA-prescribing labeling, the frequency of headaches with Nexplanaon was estimated to be about 24.9% [Ref]. With Mirena, it was estimated to be about 16.3%.

In Conclusion:

Mirena IUD for migraines in females is a fairly better and safer alternative compared to estrogen-only and estrogen-containing combined oral contraceptive pills.

It may also help in relieving menstrual migraines once it causes the menstrual cycles to stop. Women do not need any form of contraception for up to five years.

However, some women may develop headaches after its insertion which may necessitate its removal in severe cases. Other women have noticed that their headaches worsened after the removal of the Mirena IUD.

Women may need to seek medical advice if they notice unusual symptoms along with headaches like numbness and weakness of their hands and visual blurring or loss of vision.