What causes headaches during heavy menstrual periods?

Headaches During Heavy Menstrual Periods: Causes and Management

Headaches during heavy menstrual periods are most commonly due to estrogen withdrawal, which triggers menstrual migraines in susceptible women. This hormonal fluctuation is the primary mechanism behind these headaches, which can be more severe and treatment-resistant than non-menstrual migraines 1, 2.

Mechanism Behind Menstrual Headaches

Menstrual headaches typically occur due to:

1. Estrogen withdrawal: The greatest fluctuation in estrogen levels happens just before menstruation, triggering migraine attacks in susceptible women 3
2. Prostaglandin activity: Heavy menstrual periods are associated with elevated prostaglandin levels, which can cause both uterine contractions and headache pain 3
3. Iron deficiency: Heavy menstrual bleeding may lead to iron deficiency anemia, which can manifest as headaches

Types of Menstrual Migraines

Menstrual migraines are classified into two categories:

• Pure menstrual migraine: Occurs exclusively on day 1 ± 2 of menstruation in at least two out of three menstrual cycles and at no other times 2
• Menstrually-related migraine: Occurs during menstruation but may also occur at other times in the cycle 2

These migraines are typically without aura and are often more severe, longer-lasting, and more resistant to treatment than non-menstrual migraines 4.

Treatment Approach

Acute Treatment

First-line medications for acute treatment include:

1. NSAIDs (first-line for mild to moderate attacks):

   • Ibuprofen 400-800 mg every 6 hours 5
   • Naproxen 275-550 mg every 2-6 hours
   • Start early in the attack for best results 1

2. Triptans (for moderate to severe attacks):

   • Rizatriptan has the strongest evidence for acute treatment of menstrual migraine with 2-hour pain freedom rates of 33-73% 4
   • Sumatriptan is also effective with similar efficacy rates 4

Short-term Preventive Treatment

For women with predictable menstrual migraines, short-term preventive therapy can be initiated:

• NSAIDs: Start 2 days before expected menstruation and continue for 5 days 1
• Triptans:
  • Frovatriptan twice daily
  • Naratriptan twice daily
  • Zolmitriptan three times daily 4

Long-term Prevention for Frequent Attacks

For women with frequent menstrual migraines or additional migraines throughout the month:

1. Beta-blockers (first-line):

   • Propranolol 80-160 mg once or twice daily 1
   • Metoprolol 50-100 mg twice daily 1

2. Anticonvulsants (second-line):

   • Topiramate 50-100 mg daily 1
   • Note: Avoid in women of childbearing potential who aren't using reliable contraception

3. Tricyclic antidepressants (second-line):

   • Amitriptyline 10-100 mg at night 1

Hormonal Management

For women with pure menstrual migraine without aura:

• Continuous combined hormonal contraceptives with no placebo pills or using just two days of placebo pills to avoid estrogen withdrawal 2

Important caveat: Combined hormonal contraceptives are contraindicated in women with migraine with aura due to increased stroke risk 1, 6.

Non-Pharmacological Approaches

These should be used alongside medication:

• Adequate hydration
• Regular meals to maintain stable blood sugar
• Stress management techniques
• Adequate sleep
• Avoiding known migraine triggers
• Magnesium supplementation 4, 7

Special Considerations for Heavy Menstrual Bleeding

Women with heavy menstrual bleeding and associated headaches should:

1. Be evaluated for iron deficiency anemia
2. Consider hormonal management of heavy bleeding if appropriate
3. Be assessed for underlying conditions causing both heavy bleeding and headaches

When to Seek Medical Attention

Advise seeking immediate medical attention if headaches:

• Are sudden and severe ("thunderclap")
• Are accompanied by fever, stiff neck, confusion, seizures, double vision, or weakness
• Worsen after head injury
• Prevent normal daily activities
• Are not relieved by over-the-counter medications

Monitoring and Follow-up

Keep a headache diary to track:

• Headache days in relation to menstrual cycle
• Pain intensity and duration
• Response to medications
• Associated symptoms

This information helps identify patterns and optimize treatment strategies 1.