What are the treatment options for menstrual migraines?

Treatment Options for Menstrual Migraines

For menstrual migraines, initiate perimenstrual preventive treatment with a long-acting NSAID (naproxen) or triptan (frovatriptan or naratriptan) for 5 days, beginning 2 days before expected menstruation. 1

Understanding Menstrual Migraines

Menstrual migraines are divided into two categories:

• Pure menstrual migraine: Attacks occur only with menstruation (prevalence ~1%)
• Menstrually related migraine: Attacks occur both during menstruation and at other times (prevalence ~6-7%) 2

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

Treatment Approach

Acute Treatment

1. First-line medications:

   • NSAIDs (acetylsalicylic acid, ibuprofen, diclofenac potassium) 1
   • Naproxen sodium (275-550 mg every 2-6 hours) 3

2. Second-line medications:

   • Triptans (take early when pain is mild) 1
   • Sumatriptan (most studied for menstrual migraine)
     • 70% of patients report headache relief at 2 hours with 100 mg oral dose 4
     • 67% report headache relief at 4 hours 5
   • Rizatriptan has shown the best overall evidence for acute treatment with pain-free responses of 33-73% at 2 hours 2

3. Adjunct medications:

   • Antiemetics (domperidone, metoclopramide) for nausea/vomiting 1

Short-term Preventive Treatment

This approach is particularly effective for menstrual migraines:

1. Triptans:

   • Frovatriptan (2.5 mg twice daily)
   • Naratriptan (2.5 mg twice daily)
   • Zolmitriptan (2.5 mg three times daily) 2
   • Begin 2 days before expected menstruation and continue for 5 days total 1

2. NSAIDs:

   • Naproxen sodium (long-acting) 1, 2
   • Begin 2 days before expected menstruation and continue for 5 days total 1

3. Other options:

   • Magnesium supplementation 2
   • Estrogen supplementation (for pure menstrual migraine without aura) 1, 6

Daily Preventive Treatment

Consider for women with frequent, severe menstrual migraines that don't respond adequately to acute or short-term preventive treatments:

1. First-line medications:

   • Beta-blockers (propranolol 80-160 mg daily, metoprolol 50-100 mg twice daily) 1
   • Candesartan (16-32 mg daily) 1
   • Topiramate (50-100 mg daily) 1

2. Second-line medications:

   • Amitriptyline (10-100 mg at night) 1
   • Flunarizine (5-10 mg once daily) 1

Hormonal Considerations

• Women with pure menstrual migraine without aura may benefit from continuous use (without breaks) of combined hormonal contraceptives 1, 6
• IMPORTANT: Combined hormonal contraceptives are contraindicated in women with migraine with aura regardless of menstrual association due to increased stroke risk 1
• Minimizing or eliminating monthly estrogen concentration declines may be effective in preventing menstrual migraines 6

Treatment Pitfalls and Caveats

1. Medication overuse headache: Frequent use of acute medications (≥10 days/month) can lead to medication overuse headache 1, 7

2. Serotonin syndrome risk: When using triptans with SSRIs, SNRIs, or TCAs, monitor for signs of serotonin syndrome (mental status changes, autonomic instability, neuromuscular aberrations) 7

3. Triptan contraindications: Avoid in patients with:

   • Coronary artery disease
   • Prinzmetal's angina
   • History of stroke or TIA
   • Uncontrolled hypertension 7

4. NSAID risks: Long-term use can cause:

   • Gastrointestinal ulceration and bleeding
   • Cardiovascular events
   • Renal impairment 3

5. Treatment resistance: Menstrual migraines are often more resistant to treatment than non-menstrual attacks, requiring a more aggressive approach 2

By following this structured approach to menstrual migraine management, focusing on both acute treatment and prevention, most women can achieve significant relief from these particularly challenging headaches.