100 Migraine Drugs, A to Z: estrogen

Estrogen can be an effective agent for the treatment of menstrual migraines. Many women report that their migraines tend to occur before or during their period and sometimes with ovulation. For some women menstruation is the only time they get a migraine. The attacks appear to be triggered by a drop in estrogen levels. A steady estrogen level is why 2 out of 3 women stop having migraines during pregnancy and menopause.

Most women with menstrual migraines respond well to sumatriptan (Imitrex) and other triptans. If triptan alone does not provide sufficient relief, adding a nonsteroidal anti-inflammatory drug (NSAID) such as naproxen (Aleve) or ibuprofen (Advil) to a triptan can be very effective.

When this strategy does not work and the periods are very regular, mini prophylaxis is another approach. This means taking a preventive drug for a week, starting a day or two before the expected migraine attack. Mini prophylaxis can be tried with the usual preventive drugs such as beta blockers and also with a triptan, such as naratriptan (Amerge), which is somewhat longer acting than other triptans. Sumatriptan and other short-acting triptans also prevents migraine attacks and not only menstrual ones. Some of my patients who wake up every morning with a migraine take a triptan in the evening and avert the attack. This is somewhat surprising because the half-life of sumatriptan is only 2.5 hours.

If all these treatments fail, continuous intake (skipping the week of placebo pills) of an estrogen-containing contraceptive such as Lo Loestrin maintains a steady level of estrogen and can prevent occurrence of periods as well menstrual migraines and other period-related problems such as PMS, painful cramping, and excessive bleeding. It is very safe to suppress periods for at least a year. Several contraceptives are designed to be taken continuously for 3 months at a time. Unfortunately, in some women this strategy fails and they have breakthrough periods along with breakthrough migraines.

Exogenous estrogen (in contraceptives and for hormone replacement in menopause) should be avoided in women who have migraines with aura because of a slight increase in the risk of strokes. While this risk is very small, if a woman smokes or has other risk factors for strokes, taking estrogen-containing pills is definitely contraindicated. For contraception, such patients can take progesterone-only minipill containing norethindrone (Camila, Ortho Micronor).