From the Guidelines
The treatment plan for women with menstrual migraines should prioritize preventive and acute therapies tailored to the hormonal nature of these headaches, with a focus on minimizing morbidity, mortality, and improving quality of life. The most recent and highest quality study 1 suggests that for prevention, starting NSAIDs like naproxen sodium or ibuprofen 2-3 days before expected menstruation and continuing through the first few days of bleeding can be effective.
- Key considerations for preventive therapy include:
- Starting NSAIDs like naproxen sodium (550mg twice daily) or ibuprofen (600mg three times daily) 2-3 days before expected menstruation
- Using triptans preventively, with frovatriptan 2.5mg twice daily or naratriptan 1mg twice daily started 2 days before expected menstruation and continued for 5-6 days
- Considering extended or continuous hormonal contraception regimens to minimize hormone fluctuations
- For acute treatment during a migraine, triptans (sumatriptan 50-100mg, rizatriptan 10mg, zolmitriptan 2.5-5mg) are first-line options, often combined with NSAIDs for enhanced effectiveness 1.
- Additional considerations include:
- Hormonal interventions like estrogen supplementation (estradiol gel 1.5mg or patches 100μg) during the late luteal phase and menstruation for women with severe, refractory menstrual migraines
- Lifestyle modifications including stress management, regular sleep patterns, and avoiding known triggers as important complementary approaches
- Counseling patients to begin treatment of migraine headache as soon as possible after its onset, using combination therapy (such as a triptan with an NSAID or acetaminophen) to improve efficacy 1
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Treatment Plan for Menstrual Migraines
The treatment plan for women with menstrual migraines involves a combination of acute, short-term prophylaxis, and daily prevention strategies.
- Acute Treatment: Triptans, such as sumatriptan and rizatriptan, are effective for acute management of menstrual migraine 2, 3. Other options include mefenamic acid, combination sumatriptan/naproxen, and frovatriptan 2.
- Short-term Prophylaxis: Perimenstrual prophylaxis with triptans, such as frovatriptan, zolmitriptan, or naratriptan, can reduce the frequency and severity of menstrual migraine attacks 2, 3, 4. Transdermal estradiol and naproxen sodium are also effective for short-term prevention 2, 4, 5.
- Daily Prevention: Continuous combined hormonal contraceptives (CHCs) with no placebo pills or using just two days of placebo pills can help prevent menstrual migraine by avoiding estrogen withdrawal 6. However, CHCs are not recommended for women with menstrual migraine with aura, especially those with other risk factors such as smoking 6.
- Hormone Therapies: Estrogen supplementation, such as transdermal estrogen, can provide a sustained low level of estrogen and prevent menstrual migraine attacks 5.
- Non-Hormonal Options: Magnesium, dihydroergotamine, and anti-epileptic medications, such as topiramate, can be used for prevention of menstrual migraine, but caution is indicated when using anti-epileptic medications with oral contraceptives or hormonal treatments 3.
Considerations
It is essential to consider the individual patient's needs and medical history when selecting a treatment plan. Women with menstrual migraine with aura should avoid CHCs, and those with other risk factors should be closely monitored 6. Additionally, anti-epileptic medications can affect the efficacy of oral contraceptives and hormonal treatments, and caution is indicated when using these medications together 3.