What is the best treatment for menstrual migraine?

Best Treatment for Menstrual Migraine

For menstrual migraine, perimenstrual preventive treatment with a long-acting triptan (particularly frovatriptan 2.5 mg twice daily) is the most effective approach, starting 2 days before expected menstruation and continuing for 5-6 days. 1, 2

Understanding Menstrual Migraine

Menstrual migraine refers to migraine attacks that occur exclusively or frequently in association with menstruation. These attacks are often:

• Longer in duration
• More severe in intensity
• More resistant to standard acute treatments 3

Treatment Algorithm

First-Line: Perimenstrual Preventive Treatment

1. Frovatriptan 2.5 mg BID

   • Start 2 days before expected menstruation
   • Continue for 6 days
   • Most effective regimen, with over 50% of women experiencing no menstrual migraine during treatment period 2
   • Long half-life makes it particularly suitable for prevention 3

2. Alternative Triptan Options

   • Frovatriptan 2.5 mg once daily (less effective than BID but better than placebo) 2
   • Naratriptan (as mentioned in guidelines) 1

Second-Line: NSAIDs for Prevention

• Long-acting NSAIDs (e.g., naproxen)
• Start 2 days before expected menstruation
• Continue for 5 days 1

Acute Treatment Options (if breakthrough attacks occur)

1. First-line acute medications:

   • NSAIDs (ibuprofen, diclofenac potassium, acetylsalicylic acid) 1

2. Second-line acute medications:

   • Triptans (if NSAIDs are ineffective)
   • Take early in attack when headache is still mild 1
   • Sumatriptan subcutaneous injection for rapidly peaking headaches or when oral medications aren't tolerated due to vomiting 1

Special Considerations

Hormonal Management

• For women with pure menstrual migraine without aura, continuous use of combined hormonal contraceptives (without breaks) may be beneficial 1
• Important safety warning: Combined hormonal contraceptives are contraindicated in women with migraine with aura due to increased stroke risk 1, 4

For Difficult-to-Treat Cases

• Frovatriptan has shown efficacy even in women with documented inadequate response to triptans for acute treatment of menstrual migraine 5
• Consider daily preventive treatment with standard migraine preventives if attacks occur frequently outside the menstrual period 3

Evidence Quality and Efficacy

• Randomized controlled trials show frovatriptan BID reduces menstrual migraine incidence by 59% compared to placebo 2
• Frovatriptan once daily reduces incidence by 48% compared to placebo 2
• Frovatriptan also reduces severity and duration of breakthrough attacks in a dose-dependent manner 2

Safety Profile

• Frovatriptan is generally well-tolerated during short-term preventive therapy
• Adverse events are typically mild to moderate 6
• No significant differences in adverse events between frovatriptan and placebo in preventive regimens 6
• Common side effects include dizziness, paresthesia, dry mouth, and fatigue 7

Common Pitfalls to Avoid

1. Medication overuse: Limit acute medication use to prevent medication overuse headache
2. Delayed treatment: Educate patients to take acute medications early in attack
3. Inadequate duration: Ensure preventive treatment covers the entire vulnerable period (2 days before through several days after menstruation onset)
4. Ignoring hormonal contraindication: Never prescribe combined hormonal contraceptives to women with migraine with aura

By following this evidence-based approach to menstrual migraine management, focusing on perimenstrual prevention with frovatriptan, patients can experience significant reduction in attack frequency, severity, and duration.