Menstrual Migraine

Aka: Menstrual Migraine, Migraine Headache in Women

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II. Pathophysiology

  1. Headaches often improve in pregnancy
  2. Estrogen withdrawal precipitates Migraine Headaches

III. Symptoms

  1. Headache onset 2 days prior to Menses
  2. Headache lasts until final day of Menses

IV. Associated conditions

  1. Premenstrual Syndrome
  2. Dysmenorrhea

V. Management: Acute

  1. See Migraine Headache Management
  2. Menstrual Migraines tend to be more severe, prolonged and refractory to Migraine Abortive Management
  3. Most effective agents used to abort Menstrual Migraine Headaches (with current body of evidence)
    1. Triptans (esp. Sumatriptan, Rizatriptan)
      1. Triptans may be less effective in Menstrual Migraine than non-Menstrual Migraines
    2. NSAIDs
      1. Naproxen
      2. Mefanamic Acid (Ponstel)

VI. Prevention

  1. Protocol: Standard Migraine Prophylaxis
    1. See Migraine Prophylaxis
    2. Propranolol
    3. Tricyclic Antidepressants
    4. Topiramate
  2. Protocol: "Mini-Prophylaxis"
    1. Start 3 days prior to expected first day Menses
    2. Continue until Menses is finished (up to 5-6 days total)
    3. Medication Option 1: Continuous use of Migraine Abortive Treatment
      1. Risk of Analgesic Overuse Headache
      2. Naproxen (Naprosyn) 500 mg orally twice daily
        1. Alternatives: Mefenamic Acid (Ponsetl), especially if Dysmenorrhea coexists
      3. Triptans taken around the clock perimenstrually
        1. Frovatriptan 2.5 mg twice daily for 5-7 days starting 0-2 days before Menses
        2. Zolmitriptan 2.5 mg three times daily for 5-7 days starting 0-2 days before Menses
        3. Naratriptan (Amerge) 1 mg twice daily for 5-7 days starting 0-2 days before Menses
        4. Historic, alternative agents (Ergotamines, not recommended)
          1. Ergotamine 1 tab bid (significant adverse effects)
          2. Migranal (DHE Nasal)
      4. Consider Magnesium Supplementation
        1. Take 200 to 600 mg orally daily
    4. Medication Option 2: Hormonal
      1. Do not use Estrogens for Migraine with Aura, or if Hypertension or Tobacco Abuse
        1. See CVA precautions below
      2. Low Estradiol preparations (20 mcg or less)
        1. Loestrin 24 Fe
        2. Microgestin 1/20
      3. Estradiol patch started 2-3 days prior to Menses
        1. Climara 1-2 patches over 1 week
        2. Estraderm or Vivelle 2-4 patches over 1 week
      4. Consider adding Methyltestosterone 20 mg
  3. Protocol: Continuous OCP cycling with low Estrogen pills
    1. Options
      1. See Seasonal Contraception
      2. Examples: Lybrel, Lo-Seasonique, Xulane patch, NuvaRing
    2. Counsel patients on Cerebrovascular Accident risk
      1. Cerebrovascular Accident Risk in Women
      2. Stop Oral Contraceptives immediately if development of Migraines with aura or other changes
      3. Ethinyl Estradiol doses of 20 mcg or less appears safe if no contraindications (see below)
    3. Contraindications
      1. Migraine with Aura
      2. Migraine without Aura and one of the following
        1. Age >35 years old (relative contraindication)
        2. Comorbid Tobacco Abuse
        3. Hypertension

VII. Complications: Cerebrovascular Accident

  1. See Cerebrovascular Accident Risk in Women
  2. Risks include Migraine Headache with aura and Oral Contraceptive use

VIII. References

  1. (2012) Presc Lett 19(3): 14 [PubMed]
  2. Fettes (1997) Postgrad Med 101(5): 67-77 [PubMed]
  3. Maasumi (2017) Headache 57(2):194-208 +PMID:27910087 [PubMed]
  4. Matharu (2002) Practitioner 246:272-8 [PubMed]
  5. Puledda (2024) Cephalgia 44(8): 3331024241252666 [PubMed]
  6. Pringsheim (2008) Neurology 70(17): 1555-63 [PubMed]
  7. Silberstein (1995) Postgrad Med 97(4):147-53 [PubMed]

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