What are the treatment options for menstrual-related headaches?

Treatment Options for Menstrual-Related Headaches

For menstrual-related headaches, NSAIDs such as ibuprofen (400mg every 4-6 hours) are recommended as first-line treatment, with triptans as effective second-line options for more severe attacks. 1, 2

Understanding Menstrual Migraines

Menstrual migraines are classified into two categories:

• Pure menstrual migraine: Occurs exclusively on day 1 ± 2 of menstruation in at least 2 out of 3 menstrual cycles (prevalence ~1%)
• Menstrually-related migraine: Occurs during menstruation but also at other times in the cycle (prevalence ~6-7%) 2

These headaches are typically more severe, longer-lasting, and more resistant to treatment than non-menstrual migraines due to the effects of estrogen withdrawal 2, 3.

Treatment Approaches

Acute Treatment

1. First-line: NSAIDs

   • Ibuprofen 400mg every 4 hours as needed for pain relief 1
   • Particularly effective for dysmenorrhea when started at earliest onset of pain 1
   • No evidence that doses higher than 400mg provide additional benefit for acute pain 1

2. Second-line: Triptans

   • Rizatriptan shows the best overall evidence for acute treatment with pain-free responses of 33-73% at 2 hours 3
   • Sumatriptan has similar efficacy (61-63% for 2-hour pain freedom) 3
   • Most effective when administered early while pain is still mild 4

3. Combination therapy

   • Triptan plus NSAID combinations can be more effective for breaking severe attacks 5

Short-term Preventive Therapy

For predictable menstrual migraines, short-term preventive therapy can be initiated 1-2 days before expected headache onset:

1. Triptans

   • Frovatriptan (twice daily)
   • Zolmitriptan (three times daily)
   • Naratriptan (twice daily) 3

2. Non-triptan options

   • Naproxen sodium
   • Magnesium supplements (400-600mg daily)
   • Estrogen therapy (to prevent withdrawal) 5, 3

Hormonal Management

For women whose migraines are clearly triggered by estrogen withdrawal:

• Continuous combined hormonal contraceptives with no placebo pills or using just two days of placebo pills to avoid the estrogen withdrawal trigger 2
• Transdermal estrogen started just before menstruation to provide sustained estrogen levels 6

Important caveat: Combined hormonal contraceptives are contraindicated in women with menstrual migraine with aura due to increased stroke risk 2

Special Considerations

Medication Overuse

• Limit acute medication use to prevent medication overuse headache:
  • NSAIDs ≤15 days/month
  • Triptans ≤10 days/month 5

Pregnant and Breastfeeding Women

• Paracetamol (acetaminophen) is first-line for pregnant women
• NSAIDs can only be used during second trimester of pregnancy
• For breastfeeding women, paracetamol, ibuprofen, and sumatriptan are considered safe 7

Non-Pharmacological Approaches

• Regular sleep schedule
• Consistent meal times
• Adequate hydration
• Stress management techniques
• Cognitive behavioral therapy 5

Treatment Algorithm

1. Begin with patient diary tracking headaches through three complete menstrual cycles to confirm relationship to menses 4

2. For mild to moderate attacks:

   • Start with ibuprofen 400mg every 4-6 hours at earliest onset of pain 1
   • If inadequate response, consider triptan therapy

3. For severe attacks or inadequate NSAID response:

   • Use triptan (rizatriptan preferred based on evidence) 3
   • Consider triptan + NSAID combination

4. For predictable, debilitating menstrual migraines:

   • Implement short-term preventive therapy with triptans or NSAIDs starting 1-2 days before expected headache
   • Consider hormonal management if appropriate

5. For refractory cases:

   • Consult with both neurology and gynecology for integrated management 8

By following this evidence-based approach and selecting appropriate treatments based on headache severity and response, most women with menstrual-related headaches can achieve significant relief.