Treatment of Menstrual Migraine headache symptoms

Definition: Menstrual Migraine is defined by the International Classification of Headache Disrders (ICHD3 beta) as migraine without aura that occurs within days -2 and +3 of the menstrual period where menstrual onset was defined as day 1.  Menstrual migraine is further divided into pure menstrual migraine where migraine headaches only occur during the menstrual cycle or menstrually related migraine without aura where the headaches occur at menstruation and at other times during the month as well.

General:  Women with migraine are encouraged to not ignore their cycle but instead plan for it.  They are advised to relax their personal and work schedule during their cycle and to get lots of rest, exercise, and proper nutrition.  This is important because menstrual migraines are more severe, last longer, and are more difficult to treat than ahe usual migraine.  22% of women have menstrual migraine.

Charting:  The start and stop and number of days of bleeding and days of treatment specifically mentioning the name of the drugs and the quantity taken during the month should be charted by women with menstrual migraine.  This can be done with a simple pen and paper technique, a word processor type report, or by using a migraine app on a smart phone.  The National Headache Society has recommended an app called iMigraine which can be downloaded from iTunes.

When to Treat: Treat several days before, during, and after the menstrual cycle if the migraine doesn’t come consistently at the same time or if you have irregular periods.  If the migraine usually comes the day before you bleed and you have regular periods, then start treating several days before bleeding.  A variety of drugs may be tried and the following list is from simple, cheap, and few side effects to complicated, expensive, and possible side effects.

Simple Drugs to Try for Acute Therapy:  Try over the counters like Tylenol (acetaminophen), Advil (ibuprofen), or Aleve (naproxen) taken as 1-2 X/day.  Naproxen is used more often.

Triptans:  oral Imitrex (sumatriptan) 100 mg, Zomig (zomatriptan) 2.5/5 mg, Maxalt (rizatriptan) 10mg, Axert (almotriptan) 12.5 mg, Relpax (eletriptan) 40 mg, Amerge (naratriptan) 2.5 mg, or Frova (frovatriptan) 2.5 mg, taken as 1-2 X/day.  Frova and Amerge are used for menstrual migraine due to their long half-life: Frova-26 hours, and Amerge-6 hours.

For infrequent migraines triptan therapy is recommended and rizatriptan has the best evidence of pain freedom at 2 hours (63%) followed by sumatriptan (61%), almotriptan (48%), and zolmitraiptan (23-48%).

Frova, because of its long 26 hour half-life has become the drug with the most evidence as a short-term prophylactic agent for menstrual migraine.  One Frova trial demonstrated that 57% of patients were migraine free over the course of 3 menstrual cycles. The regimen used was 2.5 mg of Frovatriptan, or 1 pill twice daily, starting 2 days prior to the onset of menstruation, for a total of 6 days of treatment.  With this regimen the patient can also take an additional 2.5 mg dose once a day for breakthrough headaches.  This treatment program was efficacious in women with pure menstrual migraine, and in select, difficult to treat women with migraines where previous abortive treatments had failed.  Because of this result, short-term prevention of menstrual migraine with frovatriptan has been given an A rating by the American Headache Society and the American Academy of Neurology for migraine prevention.

Preventive drugs: Any of the group of drugs that may be used for prevention may work.  They may be taken every day during the menstrual cycle or every day of the month.  Data concerning the use of long-term preventive agents for menstrual migraine is sparse and the use of standard migraine preventive drugs is currently the most common form of therapy.  These drugs include:, Inderal (propranolol), Tenormin (atenolol), Topamax, Trokendia XR, or Quedexy XR (topiramate), and Elavil ((amitriptyline).  Depakote should not be used as it is completely contraindicated in menstruating females and has an X rated warning from the FDA regarding teratogenic damage to the fetus.

Estrogen:  Many doctors prescribe estrogen based birth control pills, estrogen IUDs, estrogen patches and pellets, and Depo-Provera injections to persons with migraine.  These drugs are all contraindicated for migraine by the FDA and can make the experience of migraine worse.  They are all relatively contraindicated by the FDA for patients with menstrually related migraine and migraine without aura, but they are absolutely contraindicated for women with migraine with aura for risk of stroke. Migraine with aura alone carries a 6 % risk of stroke.

Other problems are that estrogen treatment is called “a class 1 carcinogen” that is, a drug that may cause cancer.  The incidence of breast cancer in 1960 before the pill came out was 6% but now it is 8%.  The Mayo Clinic published an article stating there is a 6% risk of breast cancer in women.  Also these estrogen treatments can cause an abortion by making cervical mucus thick so that an embryo can’t move down the tube and implant in the uterus.  IUDs work by scraping an implanted embryo off the uterine wall, like a lawnmower cuts grass.

At this time additional data are needed to make specific recommendations regarding long-term prevention of therapy and menstrual migraine.

Elizabeth Loder published a book on menstrual migraine and is a Professor of Neurology at Harvard in Boston.  She was chosen by the American Academy of Neurology to lead a team of neurologists investigating hormonal treatment of migraine with menses.  These doctors reviewed the literature and then published the following article in the journal Headache

Loder E, Rizzoli P, Golub J. Hormonal management of migraine associated with menses and the menopause: a clinical review.  Headache.  2007;47(2):329-340.

Their summary statement is appended below.

”Hormonal treatment of migraine is not a first-line treatment strategy for most women with migraine.  Evidence is lacking regarding its long-term harms and migraine is a contraindication to the use of exogenous estrogen in all women with aura and those aged 35 or older.  The harm to benefit balances of several traditional non-hormonal therapies are better established.“

References: 

1. Vetvik KG, Macgregor EA, Lundqvist C, Russell MB. Prevalence of menstrual migraine: a population-based study. Cephalalgia. 2013;34:280-288.

2. 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;50:528-538.

3. Maasumi K, Tepper SJ, Kriegler J S. Menstrual migraine and treatment options: review. Headache. 2017;57;194-208.

4. Silbersteine SD, Arthur EH, Schreiber C, Keywood C. A randomized trial of frovatriptan for the intermittent prevention of menstrual migraine. Neurol. 2004;63:261-269.

5. Silberstein SD, Berner T, Tobin J, Xiang Q, Campbell JC. Scheduled short-term prevention with frovatriptan for migraine occurring exclusively in association with menstruation. Headache. 2009;49:1283-1297.

6. Brandes J, Poole AC, Kallela M, et al. Short-term frovatriptan for the prevention of difficult-to-treat menstrual migraine attacks. Cephalalgia. 2009;29:1133-1148.

7. Newman LC, Lipton RB, Lay CL, Solomon S. A pilot study of oral sumatriptan as intermittent prophylaxis of menstruation-related migraine. Neurol. 1997;51:307-309.

8. Tuchman MM, Hee A, Emeribe U, Silberstein S. Oral zolmitriptan in the short-term prevention of menstrual migraine: a randomized, placebo-controlled study. CNS Drugs. 2008;22:877-886.

9. Newman L, Mannix LK, Landy S, et al. Naratriptan as short-term prophylaxis of menstrually associated migraine: a randomized, double-blind, placebo-controlled study. Headache. 2001;41:248-256.

10. Coffee, AL, Sulak PJ, Hill AJ, et al. Extended cycle combined oral contraceptives and prophylactic frovatriptan during the hormone-free interval in women with menstrual-related migraines. J Womens Health (Larchmt). 2014;23:310-317.

11. Sulak P, Willis S, Kuel T, et al. Headaches and oral contraceptives: impact of eliminating the standard 7-day placebo interval. Headache. 2007;47:27-37.

12. Hullett, PW, Maasumi, K Neurology Times Tuesday, Octoeber 17, 2017