From the Guidelines
Menstrual migraines can be effectively managed with perimenstrual preventive treatment, such as daily intake of a long-acting NSAID or triptan for 5 days, beginning 2 days before the expected first day of menstruation, as recommended by the 2021 study in Nature Reviews Neurology 1.
Preventive Treatment Options
- Initiation of perimenstrual preventive treatment should be considered, as it has been shown to be effective in reducing the frequency and severity of menstrual migraines 1.
- Long-acting NSAIDs, such as naproxen, can be taken daily for 5 days, starting 2 days before the expected first day of menstruation 1.
- Triptans, such as frovatriptan or naratriptan, can also be taken daily for 5 days, starting 2 days before the expected first day of menstruation 1.
Acute Treatment Options
- For acute treatment, triptans like sumatriptan or rizatriptan are effective when taken at the first sign of headache 1.
- Combining a triptan with an NSAID often works better than either medication alone 1.
Hormonal Options
- Continuous or extended-cycle birth control pills can be used to minimize hormone fluctuations and reduce the frequency and severity of menstrual migraines 1.
- However, combined hormonal contraceptives are contraindicated in women with migraine with aura, regardless of any association with their menstrual cycle, due to an increased risk of stroke 1.
Non-Medication Approaches
- Maintaining regular sleep patterns, staying hydrated, avoiding known triggers, and stress management techniques can also help reduce the frequency and severity of menstrual migraines 1.
- Consideration of preventive treatment should be based on the individual patient's needs and medical history, as recommended by the 2021 study in Nature Reviews Neurology 1.
From the FDA Drug Label
The efficacy of zolmitriptan tablets was unaffected by ... relationship to menses; Some women get migraines around the time of their menstrual period
Menstrual Migraines are not directly affected by zolmitriptan tablets, as the drug's efficacy is unaffected by the relationship to menses. However, it is noted that some women get migraines around the time of their menstrual period. Zolmitriptan tablets can still be used to treat migraine headaches in these patients, but the drug's efficacy is not specifically influenced by the menstrual cycle 2.
From the Research
Definition and Classification of Menstrual Migraines
- Menstrual migraines can be categorized as menstrually related migraine (MRM) or pure menstrual migraine (PMM) 3
- 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 4
- Menstrually-related migraine is defined as the same but may occur at other times in the menstrual cycle, not just around menstruation 4
Pathophysiology and Treatment
- The withdrawal of estrogen has been correlated with the onset of menstrual migraines, providing an opportunity for specific treatment with hormone therapies 4
- Menstrual migraine attacks are often longer, more severe, and harder to treat than other migraine attacks 3
- Appropriate treatment strategies include acute treatment, short-term preventive treatment, and daily preventive treatment, depending on the patient's pattern of migraine and occurrence of migraine outside the menstrual period 3
Treatment Options
- Frovatriptan is the mainstay of short-term prevention 3
- Patients with PMM may be adequately managed with short-term preventive treatment started 2 days prior to the onset of migraine and continued for 5-6 days 3
- Estrogen-containing contraceptive treatment may be effective in appropriately selected patients 3, 5, 4
- Rizatriptan has the best overall evidence for acute treatment of menstrual migraines, ranging from pain-free responses of 33-73% at 2 hours 6
- Short-term prophylaxis with transcutaneous estradiol, frovatriptan, and naratriptan has grade B evidence of efficacy 5
Efficacy of Different Treatments
- A study comparing frovatriptan, transdermal oestrogens, and naproxen sodium for the short-term prevention of menstrual migraines found that frovatriptan was more effective in reducing the daily incidence of migraine and headache severity 7
- Another study reviewed numerous treatments for menstrual migraines, including sumatriptan, rizatriptan, naratriptan, zolmitriptan, and almotriptan, and found that rizatriptan had the best overall evidence for acute treatment 6