What are the treatment options for menstrual migraines?

Treatment Options for Menstrual Migraines

Triptans are the most effective treatment for both acute management and short-term prevention of menstrual migraines, with rizatriptan showing the best overall evidence for acute treatment and frovatriptan being preferred for prevention. 1, 2

Understanding Menstrual Migraines

Menstrual migraines are classified as:

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

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.

Acute Treatment Options

First-Line Treatments:

1. Triptans

   • Rizatriptan: Strongest evidence for acute treatment with 33-73% pain-free response at 2 hours 1
   • Sumatriptan: Similar efficacy to rizatriptan (61-63% for 2-hour pain freedom) 1
   • Other effective triptans: Zolmitriptan, naratriptan, almotriptan 2

2. NSAIDs

   • Ibuprofen: 400mg recommended for acute treatment 3
   • Naproxen sodium: Effective for both acute treatment and short-term prevention 1

3. Combination Therapy

   • Triptan + NSAID combinations are most effective for moderate to severe attacks 3

Administration Tips:

• Start medication as early as possible after migraine onset
• Sumatriptan subcutaneous injection provides fastest relief 3
• For nausea, consider anti-emetics like metoclopramide

Preventive Treatment Approaches

Short-Term Prevention (Mini-Prophylaxis):

For predictable menstrual migraines, start preventive medication 1-2 days before expected migraine onset and continue through vulnerable period.

1. Triptans:

   • Frovatriptan: Best evidence for short-term prevention, taken twice daily 1, 4
   • Naratriptan: Effective taken twice daily 1
   • Zolmitriptan: Effective taken three times daily 1

2. Non-Triptan Options:

   • Magnesium: Effective for short-term prevention 1
   • NSAIDs: Naproxen sodium shows good efficacy 1
   • Estrogen supplements: Can help stabilize hormone levels 1

Long-Term Daily Prevention:

For women with frequent or severe menstrual migraines:

1. First-line preventives 3:

   • Beta-blockers: Propranolol (80-240 mg/day) or timolol (20-30 mg/day)
   • Antidepressants: Amitriptyline (30-150 mg/day)
   • Antiseizure medications: Topiramate (100 mg/day) or divalproex sodium (500-1500 mg/day)

2. Hormonal Options:

   • Oral contraceptives: Consider for patients who don't respond to standard preventives 4
   • Caution: Avoid in women with migraine with aura due to increased stroke risk 4

Important Considerations and Cautions

1. Medication Overuse Risk:

   • Limit use of simple analgesics to <15 days/month
   • Limit triptans/combination analgesics to <10 days/month 3
   • Overuse can lead to medication overuse headache

2. Drug Interactions:

   • Antiepileptic medications may affect efficacy of oral contraceptives 1
   • Caution with serotonin syndrome when combining triptans with SSRIs, SNRIs, or TCAs 5

3. Contraindications for Triptans 5:

   • Coronary artery disease
   • Prinzmetal's variant angina
   • History of stroke or TIA
   • Uncontrolled hypertension
   • Wolff-Parkinson-White syndrome

4. Non-Pharmacological Approaches 3:

   • Regular sleep schedule
   • Consistent meal times
   • Adequate hydration
   • Regular exercise program
   • Stress management techniques

Treatment Algorithm

1. For acute attacks:

   • Start with rizatriptan or sumatriptan at onset of pain
   • Add NSAID for enhanced effect
   • Consider anti-emetic if nausea is prominent

2. For prevention:

   • If attacks are predictable and limited to menstruation: Use short-term prevention with frovatriptan
   • If attacks are frequent or severe throughout the month: Use daily preventive therapy with propranolol, topiramate, or amitriptyline

3. If first-line treatments fail:

   • Consider CGRP antagonists as second or third-line treatments 3
   • Evaluate for hormone-based interventions if appropriate

By tracking migraine patterns through three complete menstrual cycles, treatment can be optimized for timing and effectiveness.