Managing menstrual migraine

In the International Classification of Headache Disorders, “menstrual migraine” refers to two subtypes of migraine:¹

1. Pure menstrual migraine without aura and with aura

• Pain in a menstruating woman fulfilling criteria for migraine without aura or migraine with aura
• Migraine only on day 1 ± 2 (days −2 to +3) of menstruation in at least two out of three menstrual cycles, and at no other times of the cycle

2. Menstrually related migraine without aura and with aura

• Pain in a menstruating woman fulfilling criteria for migraine without aura or migraine with aura
• Migraine on day 1 ± 2 (days −2 to +3) of menstruation in at least two out of three menstrual cycles, and additionally at other times of the cycle

Migraine frequency and severity increase during perimenopause.² Menstruation, and consequently menstrual migraine, is more frequent as the cycle length shortens. Women with migraine face increased risk of vasomotor symptoms, anxiety, depression, and sleep disturbance.^3,4 Post menopause, migraine prevalence without aura declines from the last menstrual period.⁵

Read: The burden of VMS on women

Management of menstrual migraine

A multidisciplinary approach, such as combining neurologic and gynecologic consultations, can improve treatment of menstrual migraine compared with treatment only by a neurologist⁶

Symptomatic non-pharmacological treatments, such as breathing exercises, relaxation, and massage, are recommended for menstrual migraine in addition to pharmacological treatments.⁷ Women should have regular and adequate sleep, avoid skipping meals, engage in regular exercise, drink fluids, and avoid caffeine, tobacco, and alcohol.⁵

Acute menstrual migraine

Treatment of acute menstrual migraine follows the same guidance whether the pain is associated with menstruation or not.⁸ Recommended treatments include non-steroidal anti-inflammatory drugs (NSAID), triptans, ergots, or combination medications.⁷ However, clinical trial data suggest that in women with menstrually related migraine, perimenstrual attacks do not respond as well to acute treatments as do attacks at other times of the cycle.⁹ If the woman’s response to acute treatment is ineffective, preventive strategies should be considered.^8,9

Prevention of menstrual migraine

Preventive treatment relies on menstruation regularity, vasomotor symptoms, need for contraception, menstrual disorders, sleep disturbance or depression, and a woman’s preferences.⁵ Women with frequent menstrual or non-menstrual migraine can opt for recommended migraine prophylaxis.¹⁰ Short-term prevention includes use of triptans and/or NSAIDs, or estradiol patches or gels; long-term prevention includes oral contraceptives.⁸

Perimenstrual prophylaxis

Short-term perimenstrual prophylaxis is commonly started days before the predicted onset of the menstrual migraine. Thus, prophylaxis is limited to women who can predict onset of menstruation and/or menstrual migraine.^11,12

Oral contraceptives

There is low-quality evidence for prevention of menstrual migraine with oral contraceptives.¹³ Many studies are conducted in gynecologic settings with small samples of women who required contraception or hormonal treatments other than for menstrual migraine.¹³

Expert consensus is that extended-cycle regimens and treatments with a short hormone-free interval (HFI) are advised; if a 21/7 regimen is selected for short-term prevention of menstrual migraine, supplemental oral or transdermal oestradiol (E2) formulations could be added during HFI.¹¹ Short-term prevention is an option for women who do not need contraception and have predictable menstrual bleeding and migraine.¹¹ Transdermal E2 and transvaginal combined hormonal contraception (CHC) can stabilize hormone levels, avoiding the first-pass metabolic effect.¹³

CHC is contraindicated for migraine with aura by the American College of Obstetricians and Gynecologists and the World Health Organization, but not the International Headache Society.^14-16 The European Headache Federation and the European Society of Contraception and Reproductive Health recommend continuous hormonal contraception for women with migraine who require contraception, experience estrogen-withdrawal headache, or who benefit from treatment with CHC for medical reasons.¹¹ Continuous use of CHC is advised to prevent estrogen-withdrawal migraine triggered during breaks.¹¹ Although CHCs are not associated with increased risk of ischemic stroke, evidence for the progestogen-only pill is limited.^17,18

Read about estradiol withdrawal in VMS

References

1. IHS, 2018. The International Classification of Headache Disorders, 3rd edition. https://www.doi.org/10.1177/0333102417738202
2. Sacco, 2015. Migraine in menopausal women: A systematic review. https://www.doi.org/10.2147/ijwh.s70073
3. Faubion, 2023. Association of migraine and vasomotor symptoms. https://www.doi.org/10.1016/j.mayocp.2023.01.010
4. Faubion, 2023. Migraine and sleep quality: Does the association change in midlife women? https://www.doi.org/10.1097/gme.0000000000002149
5. Macgregor, 2020. Menstrual and perimenopausal migraine: A narrative review. https://www.doi.org/10.1016/j.maturitas.2020.07.005
6. Witteveen, 2017. Treatment of menstrual migraine; multidisciplinary or mono-disciplinary approach. https://www.doi.org/10.1186/s10194-017-0752-z
7. Ailani, 2021. The American Headache Society Consensus Statement: Update on integrating new migraine treatments into clinical practice. https://www.doi.org/10.1111/head.14153
8. Burch, 2020. Epidemiology and treatment of menstrual migraine and migraine during pregnancy and lactation: A narrative review. https://www.doi.org/10.1111/head.13665
9. Vetvik, 2021. Menstrual migraine: A distinct disorder needing greater recognition. https://www.doi.org/10.1016/s1474-4422(20)30482-8
10. Khoo, 2024. Acute and preventive treatment of menstrual migraine: A meta-analysis. https://www.doi.org/10.1186/s10194-024-01848-6
11. Sacco, 2018. Effect of exogenous estrogens and progestogens on the course of migraine during reproductive age: A consensus statement by the European Headache Federation (EHF) and the European Society of Contraception and Reproductive Health (ESCRH). https://www.doi.org/10.1186/s10194-018-0896-5
12. Martin, 2018. Menstrual migraine: New approaches to diagnosis and treatment. https://americanheadachesociety.org/wp-content/uploads/2018/05/Vincent_Martin_-_Menstrual_Martin-1.pdf
13. Nappi, 2022. Role of estrogens in menstrual migraine. https://www.doi.org/10.3390/cells11081355
14. ACOG, 2006. ACOG practice bulletin 73: Use of hormonal contraception in women with coexisting medical conditions. https://www.doi.org/10.1097/00006250-200606000-00055
15. WHO, 1998. Cardiovascular disease and use of oral and injectable progestogen-only contraceptives and combined injectable contraceptives. https://www.doi.org/10.1016/s0010-7824(98)00041-9
16. Bousser, 2000. Recommendations on the risk of ischaemic stroke associated with use of combined oral contraceptives and hormone replacement therapy in women with migraine. https://www.doi.org/10.1046/j.1468-2982.2000.00035.x
17. Warhurst, 2018. Effectiveness of the progestin-only pill for migraine treatment in women: A systematic review and meta-analysis. https://www.doi.org/10.1177/0333102417710636
18. Merki-Feld, 2019. Effect of desogestrel 75 µg on headache frequency and intensity in women with migraine: a prospective controlled trial. https://www.doi.org/10.1080/13625187.2019.1605504