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Case
The patient is illustrative. Ms. C., 26, asks for "the pill" because a friend recommends it. She has migraines about twice a month, and before each one she sees zigzag flashing lights for 20 minutes. She doesn't smoke, her blood pressure is 118/74, and her BMI is 24. She has no history of blood clots. She wants to avoid pregnancy for at least 3 years.
Question 1: How does the FNP decide which methods are safe?
The CDC's US Medical Eligibility Criteria for Contraceptive Use (US MEC) rate the safety of each method for people with specific conditions in four categories (Nguyen et al., 2024):
| Category | Meaning |
|---|---|
| 1 | No restriction on use |
| 2 | Advantages generally outweigh theoretical or proven risks |
| 3 | Theoretical or proven risks usually outweigh the advantages |
| 4 | Unacceptable health risk; the method should not be used |
Question 2: Is a combined pill safe for her?
Her visual symptoms before headaches are typical of migraine with aura. Under the US MEC, migraine with aura is category 4 for combined hormonal contraception, which includes the combined pill, patch and ring, because estrogen adds to an already raised risk of ischemic stroke in people who have migraine with aura (Nguyen et al., 2024). The pill she asked for is therefore not a safe choice.
Question 3: What can she use?
For migraine with aura, progestin-only and nonhormonal methods are rated category 1 (Nguyen et al., 2024):
| Method | Typical effectiveness | Points to discuss |
|---|---|---|
| Levonorgestrel IUD | Highly effective; lasts several years | Lighter periods; insertion visit |
| Copper IUD | Highly effective; long-lasting | No hormones; periods may be heavier at first |
| Etonogestrel implant | Highly effective; lasts several years | Irregular bleeding is common |
| Progestin-only pill | Less effective with typical use | Must be taken daily; she wanted a pill |
| Injectable (DMPA) | Effective with on-time injections | Every 3 months; possible bone density changes and weight gain |
Counseling with shared decision-making
The FNP explains why the combined pill isn't recommended for her, without alarming her, then asks what matters most: avoiding pregnancy reliably, not having to remember a daily pill, effects on periods, and whether she minds a procedure. Long-acting reversible methods are the most effective, but the choice is hers. Ms. C. wants reliable protection and lighter periods and chooses a levonorgestrel IUD. Until it is placed, she starts a progestin-only pill and uses condoms.
Follow-up and teaching
- Offer screening for sexually transmitted infections as appropriate, and explain that IUDs don't protect against them.
- Refer her for migraine management, since frequent migraines may benefit from preventive treatment.
- Tell her to return if her headache pattern changes, for example a sudden severe headache or new neurological symptoms.
- Document her migraine with aura clearly so future prescribers avoid estrogen-containing methods.
Reference
Nguyen, A. T., Curtis, K. M., Tepper, N. K., Kortsmit, K., Brittain, A. W., Snyder, E. M., Cohen, M. A., Zapata, L. B., & Whiteman, M. K. (2024). U.S. medical eligibility criteria for contraceptive use, 2024. MMWR Recommendations and Reports, 73(4), 1–126. https://doi.org/10.15585/mmwr.rr7304a1
