Transcript Related Guidelines

Menstrual Migraine

Rebecca C. Burch, MD · Harvard Medical School

Disclosures

July 23, 2020

This transcript has been edited for clarity.

We make a diagnosis of menstrual migraine when a menstruating person has migraines that are much more common during their menstrual period or around their menstrual period. There are two kinds of menstrual migraines. One is when a woman only has migraine around her menstrual period—from 2 days before to 3 days after the onset of menses—and at no other times during the month. That's called pure menstrual migraine. And then there's menstrually related migraine, which is when someone has migraines during that window—the 2 days before to 3 days after [the menses] in at least 2 out of 3 menstrual cycles but also gets some headaches scattered throughout the rest of the month as well. So, there it's more common during the menstrual window but can happen at other times of the month. Menstrually related migraine and menstrual migraine are really commonly reported in clinical settings and on a population level as well. This seems to be a really common pattern. 

There have been a few studies looking at whether menstrual migraines are more severe than migraines that occur at other times of the month and the evidence does support the idea that they are more bothersome.[2] Patients report that they're harder to treat. Studies looking at triptans for migraine during the menstrual cycle versus other times of the month show that treatment response is pretty similar. And many triptans have been studied for relief of menstrual migraines with great success. 

When we're thinking about treating menstrual migraines specifically, there's a couple of strategies that we can use. One is to do kind of a short-term mini prophylaxis. So, this is a scheduled acute treatment that's used for maybe 2 or 3 days before menses—really, whenever the patient expects the headache to come—and then take them continuously for roughly 5 days after that. And we use triptans this way, particularly the long-acting triptans naratriptan and frovatriptan. So, scheduled BID dosing for 5 days around menses. We can also use NSAIDs this way, and naproxen has been studied this way. We can use other NSAIDs also. For some women, this works perfectly; for others, it just kind of pushes the headache until they stop taking the prevention. And for those people, it's not going to be as effective a strategy. Sometimes if a patient responds very well to their acute treatment, we can just tell them it's okay to take it as often as you need during that menstrual week and sort of relax the normal prohibition we put on taking triptans more than 2 or 3 days a week. So, those are the sort of many preventive strategies. 

What's getting a lot more attention now is the idea of using hormonal regulation to reduce the frequency of the menstrual period. So, using a low-dose combined hormonal contraceptive in a continuous fashion—so, for about 3 months at a time—followed by a withdrawal menstrual period. Although even now, sometimes people are taking it for up to 6 months at a time, or really until they have breakthrough bleeding and then have a period. So, there are a lot of different strategies there that are being looked at. There are also some combined hormonal contraceptives that have a little bit of estrogen added back in during the otherwise so-called placebo week, to try and reduce the estrogen withdrawal that is believed to contribute to menstrual migraine. I should say that any woman who has migraine with aura needs to be looked at carefully before combined hormonal contraceptives are used, to assess their individual risks and benefits of using estrogen, because we know that exogenous estrogen increases the risk of stroke in women with migraine with aura.

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