From the Guidelines
Hormone replacement therapy (HRT) can be an effective treatment for menstrual migraines in perimenopausal and menopausal women, and I recommend continuous combined HRT using estradiol (such as patches at 50-100 mcg or gel at 1-2 pumps daily) along with progesterone (100-200 mg oral micronized progesterone daily) to avoid the hormonal fluctuations that trigger migraines, as supported by the most recent study 1.
Key Considerations
- Transdermal estrogen is preferred over oral forms because it provides more stable hormone levels and avoids the first-pass liver metabolism that can worsen migraines.
- For perimenopausal women still having periods, a cyclical regimen may be used initially, but continuous dosing often works better for migraine prevention.
- If breakthrough migraines occur, adding triptans like sumatriptan (50-100 mg as needed) or preventive medications such as propranolol (40-160 mg daily) or topiramate (25-100 mg daily) may help.
Rationale
Menstrual migraines are triggered by the natural drop in estrogen before menstruation, and HRT works by stabilizing these hormone levels 1. It's essential to start with lower doses and gradually increase as needed while monitoring symptoms. Some women may need to try different formulations or delivery methods to find the optimal regimen that prevents migraines without causing side effects.
Important Notes
- The risk of stroke associated with HRT use should be considered, as suggested by the USPSTF review 1.
- However, the most recent study 1 provides guidance on the use of HRT for menopausal symptoms, including menstrual migraines, and recommends individualized management.
From the Research
Menstrual Migraines and HRT
- Menstrual migraines can be categorized as menstrually related migraine (MRM) or pure menstrual migraine (PMM) 2
- Estrogen-containing contraceptive treatment may be effective in appropriately selected patients with menstrual migraines 2, 3, 4
- Hormone replacement therapy (HRT) is not directly mentioned in the studies, but estrogen-containing contraceptives are discussed as a potential treatment option for menstrual migraines 3, 4
- The withdrawal of estrogen has been correlated with the onset of menstrual migraines, providing an opportunity for specific treatment with hormone therapies 4
- Continuous combined hormonal contraceptives (CHCs) with no placebo pills or using just two days of placebo pills can be used to avoid the estrogen withdrawal trigger 4
Treatment Options
- Acute treatments for menstrual migraines include triptans, such as rizatriptan, which has the best overall evidence for acute treatment of menstrual migraines 3
- Short-term preventive treatment options include frovatriptan, zolmitriptan, or naratriptan, as well as magnesium, estrogen, naproxen sodium, or dihydroergotamine 3
- Daily preventive treatment options may be necessary for patients who experience additional attacks outside the menstrual period 2
Considerations
- Many anti-epileptic medications used in migraine prevention can affect the efficacy of oral contraceptives and hormonal treatments, so caution is indicated when these are used 3
- Topiramate has been shown to be effective in reducing the frequency of perimenstrual migraines, but its effect on HRT is not directly mentioned 5