Could menstrual-related symptoms be triggering my headaches?

Menstrual Migraine: Correlation and Management

Yes, there is a significant correlation between menstruation and headaches, particularly migraines, with specific evidence-based treatments available for menstrual-related headaches. 1

Understanding Menstrual Migraine

Menstrual migraine is classified into two types:

• Pure Menstrual Migraine: Attacks occur exclusively on day 1 ± 2 of menstruation in at least 2 out of 3 menstrual cycles and at no other time in the cycle (prevalence ~1%) 2

• Menstrually Related Migraine: Attacks occur both during menstruation (day 1 ± 2) and at other times in the cycle (prevalence ~6-7%) 2, 3

Pathophysiology

• Menstrual migraines are primarily triggered by the withdrawal of estrogen that occurs just before menstruation 3
• These migraines are typically without aura and are often more severe, longer lasting, and more resistant to treatment than non-menstrual migraines 2

Diagnostic Considerations

Research shows that approximately 75% of women with previously undiagnosed menstrual headaches actually meet diagnostic criteria for migraine 4. Key diagnostic features include:

• Recurrent headaches occurring regularly in at least 2 of 3 consecutive menstrual cycles
• Headaches typically occurring from 2 days before to 3 days after the onset of menstruation
• Usually without aura (though menstrual migraine with aura can occur) 3

Treatment Approaches

Acute Treatment

• First-line: NSAIDs (acetylsalicylic acid, ibuprofen, diclofenac potassium) 1
• Second-line: Triptans - particularly rizatriptan, which has shown the best evidence for acute treatment of menstrual migraine with pain-free responses of 33-73% at 2 hours 2
• Adjunct medication: Prokinetic antiemetics (domperidone, metoclopramide) for associated nausea/vomiting 1

Short-term Preventive Treatment

For women whose migraines are exclusively or predominantly associated with their menstrual cycle, short-term perimenstrual prophylaxis can be effective:

• Triptans:

  • Frovatriptan (twice daily)
  • Zolmitriptan (three times daily)
  • Naratriptan (twice daily) 2

• Non-triptan options:

  • Magnesium
  • Estradiol (administered premenstrually as a gel or patch at 1.5 mg/day) 1
  • Naproxen sodium
  • Dihydroergotamine 2, 5

Long-term Prevention

For women with frequent menstrually related migraines that also occur at other times:

• Hormonal options:

  • Combined oral contraceptives taken continuously (with no or minimal placebo days) to avoid estrogen withdrawal 3
  • Note: Combined hormonal contraceptives are contraindicated in women with migraine with aura due to increased stroke risk 6, 3

• Non-hormonal options:

  • Beta-blockers (propranolol, metoprolol)
  • Topiramate
  • Amitriptyline 1, 6

Important Considerations and Cautions

• Women with migraine with aura should avoid combined hormonal contraceptives due to significantly increased stroke risk 6
• Progestogen-only contraceptive methods are safe for all migraine patients 6
• Some preventive medications (particularly anti-epileptics like topiramate) can affect the efficacy of oral contraceptives 2
• Tracking headaches with a diary in relation to menstrual cycles is essential for accurate diagnosis and treatment planning 1

Conclusion

If your headaches consistently occur around menstruation, they are likely menstrual-related migraines that require specific treatment approaches. Consider tracking your headaches in relation to your menstrual cycle to confirm this pattern and discuss targeted treatment options with your healthcare provider.