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Menstrually Related Migraine

By Alan Rapoport

Migraine is a common, painful, disabling condition that affects about 12% of most western societies. It affects women three times more than men, 18% of women and 6% of men. Both boys and girls ages 6-10 can develop migraine; but by the ages of 11-13, when girls start to menstruate, it becomes a disease of women.

A typical migraine strikes 2 or 3 times per month and each attack can last 1-3 days. It is a very painful, throbbing pain, often in one eye or on one side of the head. Most patients have nausea and some throw up or vomit and may also have sensitivity to bright lights and loud noises and can be worse with any activity. If patients deny nausea they often talk about lack of appetite, feeling queasy and not wanting to eat, for fear of vomiting. Patients often prefer to lie in a dark, quiet room and have little stimulation and not eat. Mothers may need help taking care of their kids.

There are many triggers of migraine and menses is only one of them. Certain foods, alcohol, caffeine, weather changes, altitude, pollution, stress, lack of or too much sleeps all can trigger headaches in some people.

Women of child bearing potential often have a migraine attack with their menstrual cycle. That migraine may be longer and more severe and harder to treat than those at other time of the month. If migraine occurs only during the start or just before the start of menses it is called pure menstrual migraine. If it occurs then and at other times of the month, it is termed menstrually related migraine. Migraine attacks at the start of menses is also termed Catamenial migraine.

We can also call this hormonal migraine as it is due to a hormone in woman termed estrogen. It is found that falling levels of beta estradiol, starting 5 days before menstrual bleeding, seems to trigger a migraine attack. One of the treatments for this condition can be replacing estrogen for the 5 days that it falls by giving estrogen as a patch or tablet or continuing the birth control pill that a patient may be on.

Women on birth control pills can have an increase in migraine and if that happens the birth control pills should be stopped. If the headache on birth control pills occur only around their menses when the estrogen in the pill stops and they are on placebo pills for 7 days, then one should consider continuing the active pills with the estrogen all month long. There are 3 month birth control pills that give estrogen daily. Sometimes progesterone only pills or IUDs (intrauterine devices) can help to avoid headache but they can sometimes cause headaches also.

What about menopause and pre-menopause and migraine. Most women start to have even more headaches during the peri-menopausal years a few years before their menopause as their estrogen levels begin to fluctuate. About 2 years after they stop bleeding, often in their 40s or 50s, when they have gone through menopause, migraine usually gets less severe and less frequent. Women often have hot flashes in the peri-menopausal time or after menopause when they do not have enough estrogen. Treating with estrogen may help the hot flashes but is not good for the migraine or health in general. Estrogen at times can lead to certain types of cancer and stroke.

Pregnancy often helps migraineurs to feel better, especially in the second two trimesters. Many women have an increase in headache in their first trimester, and that is when they should not take medication. Then migraine seems to improve for the rest of the pregnancy  and women say they never felt better then when they were pregnant. Migraine attacks may come back at or a few weeks after delivery. If a women breast feeds, they usually do not get their headaches back till they stop breast feeding. Most medications should not be taken when you are breast feeding, but there are some exceptions.

A PMS headache, or pre-menstrual syndrome headache may occur up to a week or so before menses and is often treated with an antidepressant that raises serotonin levels.

There are lots of treatments for menstrual migraine or hormonal migraine. Giving a triptan like sumatriptan or eletriptan or zolmitriptan by tablet can help to stop a migraine in 1-2 hours. There are also nasal sprays, patches and injections of these medications. There are anti-inflammatory medications by tablet and one preparation that goes into solution and can be drunk for rapid effectiveness. You can also take aspirin, or acetaminophen or Excedrin Migraine or an opiate to try to help the pain. But headache specialists frown upon using any acute care medicines too often. Strong pain medications actually do not help migraine very much and when taken frequently can cause medication overuse headaches.

One form of mini prevention is to give a long acting triptan, frovatriptan, twice a day for some days before and during menses. This can be helpful to prevent the headaches from coming.

I like to give anti-inflammatory medications such as naproxen sodium starting 3 days before a menstrual headache and during menses. Sometimes I add a low dose of estrogen via patch at the same time, to help falling levels of estrogen.

General measures can help such as taking magnesium or vitamin B2, going through biofeedback training and relaxation techniques exercising regularly and eating well.

Menstrually related migraine and hormonal migraine are serious  and painful problems but can be effectively treated in many ways. So you should see your doctor and get expert care for this illness.

Meet the Bontriage Team

Cutting edge research and the latest technology

Robert P. Cowan

Robert P. Cowan, MD, FAAN

Professor of Neurology and Director of the Headache Facial Pain Program at Stanford University.

Founding medical director at the Keeler Center for the Study of Headache.

Alan Rapoport

Alan Rapoport, MD

Clinical Professor of Neurology at The David Geffen School of Medicine at UCLA.

Immediate Past-President of the International Headache Society.

Founder and Director-Emeritus of The New England Center for Headache.

Jim Blythe

Jim Blythe, PhD

Research Scientist at the Information Sciences Institute at the University of Southern California.

Over 5000 citations across 100 publications in artificial intelligence, knowledge acquisition, machine learning, social network analysis and security.

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