Migraine is a common and debilitating disorder that affects millions of Americans. Though migraine occurs with the same frequency in boys and girls, after puberty the girls outnumber boys. By adulthood, women are three times as likely to suffer from migraine as men. This is probably due to hormonal fluctuations which occur during women’s menstrual cycle, which can trigger headaches. Up to 60% of women with migraines report headaches around the time of menstruation. Approximately 7-14% of women have migraines exclusively at this time of the month. Migraines subside in 2 out of 3 women during pregnancy and after menopause – two conditions with steady estrogen levels.
Migraine can occur before, during, or after menstruation. Menstrual migraine is defined as a headache attack that occurs two days before and up to three days after the onset of a woman’s period. The most common day on which menstrual migraine occurs is the first day of bleeding. Menstrual migraine is thought to be triggered by changes in hormone levels that occur during the menstrual cycle. The most likely cause is the fall in estrogen levels that takes place just before the beginning of menses. However, the full mechanism is not yet fully understood.
Treatment of menstrual migraines requires special considerations. Women should be aware that many of the drugs used in treating migraine are potentially dangerous in pregnancy. Also, menstrual migraine is often more difficult to treat than non-menstrual migraine. Women sometimes have to try several different treatment options before finding headache relief.
The first step in management is to establish the correlation between migraines and menstruation. If the pattern is not clear, keeping a headache diary for several months can help. Once the connection is determined, treatment can be adjusted accordingly. If migraines occur only around menstruation, acute therapy may be sufficient. Medications may include anti-nausea drugs, non-steroidal anti-inflammatory agents (naproxen or Aleve, ibuprofen or Advil, aspiring/magnesium or Migralex, and others) and the triptans (such as Imitrex or sumatriptan, Zomig, Frova, Amerge, Axert, Maxalt and Relpax), amongst others. Magnesium infusions which we routinely give at our headache clinic can abort a menstrual migraine acutely and if given before the period can effectively prevent it.
Women who don’t respond to acute therapy or suffer from more than 3-4 headaches per month may require preventive treatment. This may be either in the form of short-term daily medication taken prior to the menstrual migraine or medication taken throughout the entire month. Daily magnesium supplements, or a magnesium injection several days before the expected onset of menstruation, are usually very effective in preventing menstrual migraines. Magnesium also has the added benefit of being safe in pregnancy. For very frequent migraines, one of the best preventive therapies is Botox injections, which are safer in pregnancy (and outside pregnancy) than any drug.
If menstrual migraines persist despite the above measures, hormonal therapy may be considered. This type of treatment should be initiated and monitored in consultation with the gynecologist. It often involves continuous contraception with an oral contraceptive such as Seasonale which is taken for three months continuously or Lybrel, which prevents menstruation for a year. In addition to medications, lifestyle changes can be helpful in menstrual migraine. These include avoiding known triggers, keeping regular sleep hours, biofeedback or meditation, frequent aerobic exercise and eating at regular intervals.