II. Pathophysiology
- Estrogen withdrawal precipitates Migraine Headaches
- Headaches often improve in pregnancy
IV. Associated conditions
V. Management: Acute
- See Migraine Headache Management
- Most effective agents used to abort Menstrual Migraine Headaches (with current body of evidence)
- Sumatriptan
- Rizatriptan
- Mefanamic Acid (Ponstel)
VI. Prevention
- Protocol: Standard Migraine Prophylaxis
- Protocol: "Mini-Prophylaxis"
- Start 3 days prior to expected first day Menses
- Continue until Menses is finished (up to 5-6 days total)
- Medication Option 1: Continuous use of Migraine Abortive Treatment
- Risk of Analgesic Overuse Headache
- Naprosyn 500 mg orally twice daily
- Alternatives: Mefenamic Acid (Ponsetl), especially if Dysmenorrhea coexists
- Frovatriptan (Frova), Zolmitriptan (Zomig) or Naratriptan (Amerge) taken around the clock perimenstrually
- Frovatriptan 2.5 mg twice daily for 5-7 days starting 0-2 days before Menses
- Zolmitriptan 2.5 mg three times daily for 5-7 days starting 0-2 days before Menses
- Alternatives include Ergotamine 1 tab bid (significant adverse effects) or Migranal (DHE Nasal)
- Consider Magnesium Supplementation
- Medication Option 2: Hormonal
- Do not use Estrogens for Migraine with Aura, or if Hypertension or Tobacco Abuse
- See CVA precautions below
- Low Estradiol preparations (20 mcg or less)
- Estradiol patch started 2-3 days prior to Menses
- Climara 1-2 patches over 1 week
- Estraderm or Vivelle 2-4 patches over 1 week
- Consider adding Methyltestosterone 20 mg
- Do not use Estrogens for Migraine with Aura, or if Hypertension or Tobacco Abuse
- Protocol: Continuous OCP cycling with low Estrogen pills
- Options
- See Seasonal Contraception
- Examples: Lybrel, Lo-Seasonique, Xulane patch, NuvaRing
- Counsel patients on Cerebrovascular Accident risk
- Cerebrovascular Accident Risk in Women
- Stop Oral Contraceptives immediately if development of Migraines with aura or other changes
- Ethinyl Estradiol doses of 20 mcg or less appears safe if no contraindications (see below)
- Contraindications
- Migraine with Aura
- Migraine without Aura and one of the following
- Age >35 years old (relative contraindication)
- Comorbid Tobacco Abuse
- Hypertension
- Options
VII. Complications: Cerebrovascular Accident
- See Cerebrovascular Accident Risk in Women
- Risks include Migraine Headache with aura and Oral Contraceptive use
VIII. References
- (2012) Presc Lett 19(3): 14 [PubMed]
- Fettes (1997) Postgrad Med 101(5): 67-77 [PubMed]
- Maasumi (2017) Headache 57(2):194-208 +PMID:27910087 [PubMed]
- Matharu (2002) Practitioner 246:272-8 [PubMed]
- Pringsheim (2008) Neurology 70(17): 1555-63 [PubMed]
- Silberstein (1995) Postgrad Med 97(4):147-53 [PubMed]