From the Guidelines
Post-menstrual headaches can be effectively managed with optimized acute medication therapy, and for some women, this may involve treating pure menstrual migraine. For women experiencing post-menstrual headaches, it is essential to understand that approximately 8% of women with migraine experience migraine attacks that are exclusively related to their menstruation, referred to as pure menstrual migraine 1. To manage these headaches, a combination of medication and lifestyle adjustments can be beneficial. Some key considerations include:
- Staying hydrated by drinking at least 8 glasses of water daily to prevent dehydration, which can worsen headaches
- Ensuring adequate rest to help regulate hormonal changes
- Considering stress-reduction techniques like deep breathing or meditation to mitigate the impact of stress on migraine symptoms
- Tracking headaches in relation to the menstrual cycle to identify patterns and improve management strategies In terms of medication, optimized acute medication therapy is crucial, and if this does not suffice, further treatment options may be necessary, as noted in the diagnosis and management of migraine in ten steps 1. It is also important to recognize that post-menstrual headaches often occur due to the rapid drop in estrogen levels after menstruation, which affects blood vessels and pain receptors in the brain. If headaches are severe or persistent, consulting a healthcare provider is essential, as they might recommend hormonal treatments or preventive medications to help manage symptoms.
From the Research
Definition and Classification of Menstrual Migraine
- Menstrual migraine (MM) is divided into two categories: pure menstrual migraine and menstrually-related migraine 2.
- Pure menstrual migraine is defined as a migraine occurring exclusively on day 1 ± 2 of menstruation in at least two out of three menstrual cycles and at no other time in the cycle 2.
- Menstrually-related migraine is defined as the same but may occur at other times in the menstrual cycle, not just around menstruation 2.
Treatment Options for Menstrual Migraine
- The withdrawal of estrogen has been correlated with the onset of MM, providing an opportunity for specific treatment with hormone therapies 2.
- Traditionally, MM has been treated with nonspecific treatments such as abortive and prophylactic non-steroidal anti-inflammatory drugs and triptans 2.
- Evidence suggests that nonspecific treatments can be used in combination with specific hormone treatments 2.
- Rizatriptan has the best overall evidence for acute treatment of MM, ranging from pain-free responses of 33-73% at 2 hours 3.
- For short-term prevention of MM, frovatriptan, zolmitriptan, or naratriptan, as well as magnesium, estrogen, naproxen sodium, or dihydroergotamine may be useful 3.
Prevention of Menstrual Migraine
- Predictable menstrual attacks offer the opportunity for perimenstrual prophylaxis taken only during the time of increased migraine incidence 4.
- There is grade B evidence of efficacy for short-term prophylaxis with transcutaneous estradiol, frovatriptan, and naratriptan 4.
- Contraceptive strategies offer the opportunity for treating menstrual migraine in women who also require effective contraception 4.
- Triptans have strong evidence for treatment in both acute and short term prevention of menstrual migraine 5.
Influence of Combined Oral Contraceptives on Menstrual Migraine
- The influence of combined oral contraceptives (COCs) on perimenstrual migraine is still unclear 6.
- Use of COCs showed no statistically significant overall effect on the course of perimenstrual migraine in menstruating women with migraine 6.
- However, users were at higher risk for any headache premenstrually and non-users at higher risk for migraine on days 4+ of menstruation 6.