What are the treatment options for menstrual migraines?

Treatment Options for Menstrual Migraines

For menstrual migraines, triptans are the most effective treatment option, with rizatriptan showing the best overall evidence for acute treatment and frovatriptan being the preferred choice for short-term prevention. 1

Understanding Menstrual Migraine

Menstrual migraine is categorized into two types:

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

Menstrual migraines are typically more severe, longer-lasting, and more resistant to treatment than non-menstrual migraines due to hormonal fluctuations, particularly estrogen 1.

Acute Treatment Options

First-line Medications:

1. Triptans:

   • Rizatriptan: Shows the best overall evidence for acute treatment with pain-free responses of 33-73% at 2 hours 1
   • Sumatriptan: Comparable efficacy to rizatriptan (61-63% pain freedom at 2 hours) 1
   • Zolmitriptan: Effective for moderate to severe attacks 2

2. NSAIDs:

   • Ibuprofen: 400-800 mg every 6 hours (maximum 2.4g/day) 2
   • Naproxen: Effective for short-term prevention 1
   • Aspirin: 650-1000 mg every 4-6 hours (maximum 4g/day) 2

3. Combination Therapy:

   • Triptan + NSAID combination has high-strength evidence for breaking severe migraine attacks 2

Treatment Algorithm:

1. For mild to moderate attacks:

   • Start with NSAIDs (ibuprofen or naproxen)
   • If inadequate response, escalate to a triptan

2. For moderate to severe attacks:

   • Start with a triptan (preferably rizatriptan or sumatriptan)
   • Consider combination therapy with NSAID + triptan for severe attacks

3. For nausea:

   • Add an antiemetic if needed

Short-term Preventive Treatment

For predictable menstrual migraines, short-term prevention starting 1-2 days before expected headache can be effective:

1. Triptans:

   • Frovatriptan: Twice daily dosing shows the strongest evidence 1
   • Naratriptan: Twice daily dosing 1
   • Zolmitriptan: Three times daily dosing 1

2. Non-triptan options:

   • Naproxen sodium: Effective for short-term prevention 1
   • Magnesium supplements 1
   • Estrogen supplementation (for those with estrogen withdrawal headaches) 1

Long-term Preventive Treatment

For frequent or severe menstrual migraines that also occur at other times of the month:

1. Beta-blockers:

   • Propranolol: 80-240 mg/day 2
   • Avoid in patients with asthma, heart failure, Raynaud's disease, or depression 2

2. Antidepressants:

   • Amitriptyline: 30-150 mg/day 2

3. Anticonvulsants:

   • Topiramate: 100 mg/day 2
   • Divalproex sodium: 500-1500 mg/day (contraindicated during pregnancy) 2

4. Other options:

   • Candesartan: 16-32 mg/day as an alternative to beta-blockers 2

Special Considerations

Medication Overuse Risk

• Limit acute medication use to prevent medication overuse headache:
  • NSAIDs ≤15 days/month
  • Triptans ≤10 days/month 2

Pregnancy and Breastfeeding

• Pregnancy: Paracetamol (acetaminophen) is the first-line treatment 2
• Breastfeeding: Paracetamol is preferred; ibuprofen and sumatriptan are considered safe options 2

Contraception Considerations

• Many antiepileptic medications used for migraine prevention can affect oral contraceptive efficacy 1
• Topiramate has minimal effect on oral contraceptives at doses below 200 mg/day 1
• Valproate is contraindicated during pregnancy due to teratogenicity 2

Treatment Efficacy Monitoring

• Evaluate response after 4-6 weeks of treatment
• Continue effective prophylactic treatment for at least 3-6 months before attempting discontinuation
• Use a headache diary to track menstrual cycles and headache patterns to guide treatment decisions 2

Common Pitfalls to Avoid

1. Misdiagnosis: 75% of women with undiagnosed menstrual headaches meet diagnostic criteria for migraine 3

2. Inadequate acute treatment: Treating too late when pain is severe rather than early when mild

3. Medication overuse: Using acute medications too frequently can lead to medication overuse headache

4. Ignoring hormonal influences: Failing to track menstrual cycles and their relationship to migraine attacks

5. Inappropriate preventive strategy: Using daily prevention when short-term prevention around menses would suffice

By following this evidence-based approach to menstrual migraine management, clinicians can significantly improve outcomes for women suffering from this particularly challenging form of migraine.