Current Treatment Options in Neurology

, Volume 14, Issue 1, pp 1–14

Menstrual Migraine: Update on Pathophysiology and Approach to Therapy and Management

Headache (JR Couch, Section Editor)

Opinion statement

Menstrual migraine (MM) is often reported to be more severe and more resistant to treatment than other migraines. Nevertheless, initial treatment should be the same as for any migraine. When results of acute therapy are incomplete or unsatisfactory, preventive strategies are warranted, including both pharmacologic preventives and careful adherence to lifestyle modifications. Where MM differs from other attacks is in its predictable timing and discrete precipitants. These differences allow for unique preventive strategies that target either the timing of the attacks or their hormonal precipitants. Nonspecific MM strategies—those that do not address the hormonal mechanism—include scheduled dosing of nonsteroidal anti-inflammatory drugs (NSAIDs) or triptans throughout the menstrual window. NSAIDs are a good choice when there is comorbid dysmenorrhea and allow for treatment of breakthrough headaches with triptans. Both strategies require that the timing of MM is highly predictable. Specific strategies for MM are those that reduce or eliminate the premenstrual decline in estradiol that predictably precipitates attacks. These include continuous or extended-cycle dosing of combined hormonal contraceptives (CHCs). A number of common gynecologic comorbidities argue for early adoption of these treatments, as CHCs effectively treat dysmenorrhea, menorrhagia, ovarian cysts, endometriosis, and irregular cycles. In the author’s experience, hormonal preventives are the best approach for most women whose menstrual attacks are resistant to acute therapy. They afford the greatest therapeutic benefit in prevention while treating common comorbidities and allowing for acute treatment with triptans when needed.

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Silberstein SD, Merriam GR. Sex hormones and headache. J Pain Symptom Manage. 1993;8:243–59.CrossRefGoogle Scholar
  2. 2.
    Lipton RB, Stewart WF, Diamond S, et al. Prevalence and burden of migraine in the United States: data from the American Migraine Study II. Headache. 2001;41:646–57.PubMedCrossRefGoogle Scholar
  3. 3.
    Victor TW, Hu X, Campbell JC, et al. Migraine prevalence by age and sex in the United States: a life-span study. Cephalalgia. 2010;30(9):1065–72.PubMedCrossRefGoogle Scholar
  4. 4.
    Bille BS. Migraine in school children. A study of the incidence and short-term prognosis, and a clinical, psychological and electroencephalographic comparison between children with migraine and matched controls. Acta Paediatr. 1962;51 suppl 136:1–151.Google Scholar
  5. 5.
    Epstein MT, Hockaday JM, Hockaday TD. Migraine and reproductive hormones throughout the menstrual cycle. Lancet. 1975;1:543–8.PubMedCrossRefGoogle Scholar
  6. 6.
    Neri I, Granella F, Nappi R, et al. Characteristics of headache at menopause: a clinico-epidemiologic study. Maturitas. 1993;17:31–7.PubMedCrossRefGoogle Scholar
  7. 7.
    Launer LJ, Terwindt GM, Ferrari MD. The prevalence and characteristics of migraine in a population-based cohort: the GEM study. Neurology. 1999;53:537–42.PubMedGoogle Scholar
  8. 8.
    Lay CL, Newman LC. Menstrual migraine: approaches to management. CNS Drugs. 1999;12:189–95.CrossRefGoogle Scholar
  9. 9.
    Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders: 2nd edn. Cephalalgia. 2004;24 suppl 1:9–160.Google Scholar
  10. 10.
    Edelson RN. Menstrual migraine and other hormonal aspects of migraine. Headache. 1985;25:376–9.PubMedCrossRefGoogle Scholar
  11. 11.
    Couturier EG, Bomhof MA, Neven AK, van Duijn NP. Menstrual migraine in a representative Dutch population sample: prevalence, disability and treatment. Cephalalgia. 2003;23:302–8.PubMedCrossRefGoogle Scholar
  12. 12.
    Stewart WF, Lipton RB, Chee E, et al. Menstrual cycle and headache in a population sample of migraineurs. Neurology. 2000;55:1517–23.PubMedGoogle Scholar
  13. 13.
    Pinkerman B, Holroyd K. Menstrual and nonmenstrual migraines differ in women with menstrually-related migraine. Cephalalgia. 2010;30(10):1187–94.PubMedCrossRefGoogle Scholar
  14. 14.
    Schoenen J, Sawyer J. Zolmitriptan (Zomig, 311C90), a novel dual central and peripheral 5HT1B/1D agonist: an overview of efficacy. Cephalalgia. 1997;17 suppl 18:28–40.PubMedGoogle Scholar
  15. 15.
    Salonen R, Saiers J. Sumatriptan is effective in the treatment of menstrual migraine: a review of prospective studies and retrospective analysis. Cephalalgia. 1999;19:16–9.PubMedCrossRefGoogle Scholar
  16. 16.
    Silberstein SD, Massiou H, Le Jeunne C, et al. Rizatriptan in the treatment of menstrual migraine. Obstet Gynecol. 2000;96:237–42.PubMedCrossRefGoogle Scholar
  17. 17.••
    MacGregor EA, Victor TW, Hu X, et al. Characteristics of menstrual vs nonmenstrual migraine: a post hoc, within-woman analysis of the usual-care phase of a nonrandomized menstrual migraine clinical trial. Headache. 2010;50(4):528–38.PubMedCrossRefGoogle Scholar
  18. 18.
    Calhoun A, Ford S. Elimination of menstrual-related migraine beneficially impacts chronification and medication overuse. Headache. 2008;48:1186–93.PubMedCrossRefGoogle Scholar
  19. 19.•
    Evidence-based guidelines for migraine headache in the primary care setting: pharmacological management of acute attacks. The American Academy of Neurology. Available at: http://www.ahsnet.org/ guidelines.php. Accessed June, 2011. This website provides a review of American Academy of Neurology guidelines for acute treatment of migraine.
  20. 20.
    Calhoun AH, Ford S. Behavioral sleep modification may revert transformed migraine to episodic migraine. Headache. 2007;47:1178–83.PubMedCrossRefGoogle Scholar
  21. 21.
    Baker FC, Driver HS. Self-reported sleep across the menstrual cycle in young, healthy women. J Psychosom Res. 2004;56:239–43.PubMedCrossRefGoogle Scholar
  22. 22.
    Hollander LE, Freeman EW, Sammel MD, et al.: M. Sleep quality, estradiol levels, and behavioral factors in late reproductive age women. Obstet Gynecol 2001;98:391–397.Google Scholar
  23. 23.
    Pringsheim T, Davenport WJ, Dodick D. Acute treatment and prevention of menstrually related migraine headache: evidence-based review. Neurology. 2008;70(17):1555–63.PubMedCrossRefGoogle Scholar
  24. 24.•
    Mannix LK, Martin VT, Cady RK, et al. Combination treatment for menstrual migraine and dysmenorrhea using sumatriptan-naproxen: two randomized controlled trials. Obstet Gynecol. 2009;114(1):106–13.PubMedGoogle Scholar
  25. 25.
    Lipton RB, Stewart WF, Ryan Jr RE, et al. Efficacy and safety of acetaminophen, aspirin, and caffeine in alleviating migraine headache pain: three double-blind, randomized, placebo-controlled trials. Arch Neurol. 1998;55:210–7.PubMedCrossRefGoogle Scholar
  26. 26.
    Silberstein SD, Lipton RB, Goadsby PJ, editors. Headache in clinical practice. Oxford: ISIS Medical Media; 1998.Google Scholar
  27. 27.
    Diener HC, Montagna P, Gacs G, et al. Efficacy and tolerability of diclofenac potassium sachets in migraine: a randomized, double-blind, cross-over study in comparison with diclofenac potassium tablets and placebo. Cephalalgia. 2006;26:537–47.PubMedCrossRefGoogle Scholar
  28. 28.
    Giacovazzo M, Gallo MF, Guidi V, Rico R, Scaricabarozzi I. Nimesulide in the treatment of menstrual migraine. Drugs. 1993;46 Suppl 1:140–1.PubMedCrossRefGoogle Scholar
  29. 29.
    Al-Waili NS. Treatment of menstrual migraine with prostaglandin synthesis inhibitor mefenamic acid: double-blind study with placebo. Eur J Med Res. 2000;5:176–82.PubMedGoogle Scholar
  30. 30.
    Rapoport AM, Tepper SJ, Bigal ME, Sheftell FD. The triptan formulations: how to match patients and products. CNS Drugs. 2003;17:431–47.PubMedCrossRefGoogle Scholar
  31. 31.
    Nett R, Landy S, Shackelford S, Richardson MS, et al. Pain-free efficacy after treatment with sumatriptan in the mild pain phase of menstrually associated migraine. Obstet Gynecol. 2003;102:835–42.PubMedCrossRefGoogle Scholar
  32. 32.
    Mannix LK, Loder E, Nett R, et al. Rizatriptan for the acute treatment of ICHD-II proposed menstrual migraine: two prospective, randomized, placebo-controlled, double-blind studies. Cephalalgia. 2007;27:414–21.PubMedCrossRefGoogle Scholar
  33. 33.
    Tuchman M, Hee A, Emeribe U, et al. Efficacy and tolerability of zolmitriptan oral tablet in the acute treatment of menstrual migraine. CNS Drugs. 2006;20:1019–26.PubMedCrossRefGoogle Scholar
  34. 34.
    Massiou H, Jamin C, Hinzelin G, et al. Efficacy of oral naratriptan in the treatment of menstrually related migraine. Eur J Neurol. 2005;12(10):774–81.PubMedCrossRefGoogle Scholar
  35. 35.
    Allais G, Tullo V, Benedetto C, et al. Efficacy of frovatriptan in the acute treatment of menstrually related migraine: analysis of a double-blind, randomized, multicenter, Italian, comparative study versus zolmitriptan. Neurol Sci. 2011;32 Suppl 1:S99–104.PubMedCrossRefGoogle Scholar
  36. 36.
    Allais G, Acuto G, Cabarrocas X, et al. Efficacy and tolerability of almotriptan versus zolmitriptan for the acute treatment of menstrual migraine. Neurol Sci. 2006;27 Suppl 2:S193–197.PubMedCrossRefGoogle Scholar
  37. 37.
    Sances G, Martignoni E, Fioroni L, et al. Naproxen sodium in menstrual migraine prophylaxis: a doubleblind placebo controlled study. Headache. 1990;30:705–9.PubMedCrossRefGoogle Scholar
  38. 38.
    Allais G, Bussone G, De Lorenzo C, et al. Naproxen sodium in short-term prophylaxis of pure menstrual migraine: pathophysiological and clinical considerations. Neurol Sci. 2007;28 Suppl 2:S225–8.PubMedCrossRefGoogle Scholar
  39. 39.
    Von Seggern RL, Mannix LK, Adelman JU. Rofecoxib in the prevention of perimenstrual migraine: an open-label pilot trial. Headache. 2004;44:160–5.CrossRefGoogle Scholar
  40. 40.
    Newman LC, Lipton RB, Lay CL, Solomon S. A pilot study of oral sumatriptan as intermittent prophylaxis of menstruation-related migraine. Neurology. 1998;51:307–9.PubMedGoogle Scholar
  41. 41.
    Newman LC, Mannix LK, Sandy S, et al. Naratriptan as short-term prophylaxis of menstrually-associated migraine: A randomized, double-blind, placebo-controlled study. Headache. 2001;41:248–56.PubMedCrossRefGoogle Scholar
  42. 42.
    Silberstein SD, Elkind AH, Schreiber C, Keywood C. A randomized trial of frovatriptan for the intermittent prevention of menstrual migraine. Neurology. 2004;63:261–9.PubMedGoogle Scholar
  43. 43.
    Tepper S, Freitag F. Prophylactic use of frovatriptan for menstrually associated migraine is effective and does not cause rebound migraine in the postdosing period (abstract). Headache. 2003;43:585.CrossRefGoogle Scholar
  44. 44.
    Singer R, Schim J. Frovatriptan for prophylaxis of menstrually associated migraine: efficacy and tolerability in patients using oral contraceptives compared to nonusers (abstract). Headache. 2003;43:587.Google Scholar
  45. 45.
    Marcus DA, Bernstein CD, Sullivan EA, et al. Perimenstrual eletriptan prevents menstrual migraine: an open-label study. Headache. 2010;50(4):551–62.PubMedCrossRefGoogle Scholar
  46. 46.
    Calhoun A. Four hypotheses for understanding menstrual migraine. The Female Patient. 2004;29:38–44.Google Scholar
  47. 47.
    MacGregor EA, Frith A, Ellis J, et al. Prevention of menstrual attacks of migraine: a double-blind placebo-controlled crossover study. Neurology. 2006;67:2159–63.PubMedCrossRefGoogle Scholar
  48. 48.
    de Lignieres B, Vincens M, Mauvais-Jarvis P, et al. Prevention of menstrual migraine by percutaneous oestradiol. Br Med J (Clin Res Ed). 1986;293:1540.CrossRefGoogle Scholar
  49. 49.••
    Calhoun AH, Hutchinson S. Hormonal therapies for menstrual migraine. Curr Pain Headache Rep. 2009;13:381–385.PubMedCrossRefGoogle Scholar
  50. 50.
    Sulak P, Willis S, Kuehl T, Coffee A, et al. Headaches and oral contraceptives: impact of eliminating the standard 7-day placebo interval. Headache. 2007;47:27–37.PubMedGoogle Scholar
  51. 51.
    WHO Collaborative Study of Cardiovascular Disease and Steroid Hormone Contraception. Ischaemic stroke and combined oral contraceptives: results of an international, multicentre, case-control study. Lancet. 1996;348:498–505.CrossRefGoogle Scholar
  52. 52.
    Petitti DB, Sidney S, Bernstein A, et al. Stroke in users of low-dose oral contraceptives. N Engl J Med. 1996;335:8–15.PubMedCrossRefGoogle Scholar
  53. 53.
    Chan WS, Ray J, Wai EK, et al. Risk of stroke in women exposed to low-dose oral contraceptives: a critical evaluation of the evidence. Arch Intern Med. 2004;164:741–7.PubMedCrossRefGoogle Scholar
  54. 54.
    MacGregor EA. Oestrogen and attacks of migraine with and without aura. Lancet Neurol. 2004;3:354–61.PubMedCrossRefGoogle Scholar
  55. 55.
    Donaghy M, Chang CL, Poulter N. Duration, frequency, recency, and type of migraine and the risk of ischaemic stroke in women of childbearing age. J Neurol Neurosurg Psychiatry. 2002;73:747–50.PubMedCrossRefGoogle Scholar
  56. 56.
    Calhoun A, Ford S, Pruitt A. Extended-cycle use of a ring contraceptive may reduce frequency of migraine aura. Washington: Am Headache Soc Annual Scientific Meeting; 2011.Google Scholar
  57. 57.
    Herzog AG. Continuous bromocriptine therapy in menstrual migraine. Neurology. 1997;48:101–2.PubMedGoogle Scholar
  58. 58.
    Hockaday JM, Peet KM, Hockaday TD. Bromocriptine in migraine. Headache. 1976;16:109–14.PubMedCrossRefGoogle Scholar
  59. 59.
    Wang SJ, Fuh JL, Lu SR, Juang KD, Wang PH. Migraine prevalence during menopausal transition. Headache. 2003;43:470–8.PubMedCrossRefGoogle Scholar
  60. 60.
    Calhoun AH. Migraine and menopause. Headache. 2004;44:106.PubMedCrossRefGoogle Scholar
  61. 61.
    Facchinetti F, Sances G, Borella P, et al. Magnesium prophylaxis of menstrual migraine: effects on intracellular magnesium. Headache. 1991;31:298–301.PubMedCrossRefGoogle Scholar
  62. 62.
    Burke BE, Olson RD, Cusack BJ. Randomized, controlled trial of phytoestrogen in the prophylactic treatment of menstrual migraine. Biomed Pharmacother. 2002;56:283–8.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  1. 1.Carolina Headache InstituteChapel HillUSA

Personalised recommendations