What are the treatment options for menstrual migraines?

Treatment Options for Menstrual Migraines

For menstrual migraines, a combination approach using NSAIDs or triptans for acute treatment and short-term prophylaxis with frovatriptan, naratriptan, or estradiol is most effective based on current evidence. 1, 2, 3

Understanding Menstrual Migraines

Menstrual migraines occur in relation to the menstrual cycle and are classified as:

• Pure menstrual migraine: Attacks occurring exclusively on day 1 ± 2 of menstruation
• Menstrually-related migraine: Attacks occurring around menstruation but also at other times 4

These migraines are typically more severe, longer-lasting, and less responsive to treatment than non-menstrual migraines, likely due to estrogen withdrawal during the menstrual cycle 5, 2.

Treatment Approach

Acute Treatment Options

1. First-line options:

   • NSAIDs: Naproxen sodium, ibuprofen, aspirin, mefenamic acid (500mg) 1, 2
   • Triptans:
     • Sumatriptan (50-100mg)
     • Rizatriptan (10mg) - strongest evidence for acute treatment with 33-73% pain-free response at 2 hours 3
     • Combination sumatriptan/naproxen (85mg/500mg) 2

2. Other options:

   • Combination analgesics (acetaminophen + aspirin + caffeine) 1
   • Antiemetics (e.g., metoclopramide) when nausea/vomiting are present 1

Preventive Treatment Strategies

Short-term Prophylaxis (Perimenstrual)

For women with predictable menstrual cycles who experience migraines primarily around menstruation:

1. Triptans (started 2 days before expected headache and continued for 5-7 days):

   • Frovatriptan 2.5mg twice daily - strongest evidence 1, 2, 3
   • Naratriptan 1mg twice daily 2, 3
   • Zolmitriptan three times daily 3

2. Hormonal options:

   • Transdermal estradiol 1.5mg (applied 3 days before expected migraine) 2, 3

3. Other options:

   • Magnesium supplementation 3
   • Naproxen sodium 3
   • Dihydroergotamine 3

Continuous Preventive Therapy

For women with frequent or severe menstrual migraines:

1. First-line preventives:

   • Beta-blockers: Propranolol (80-240mg/day), Timolol (20-30mg/day) 1, 6
   • Anticonvulsants: Topiramate (100mg/day), Divalproex sodium (500-1500mg/day) 1
   • Antidepressants: Amitriptyline (30-150mg/day) 1

2. Hormonal strategies (for women also needing contraception):

   • Continuous combined hormonal contraceptives with no or minimal hormone-free interval to prevent estrogen withdrawal 4
   • Caution: Combined hormonal contraceptives are contraindicated in women with migraine with aura 4

Treatment Algorithm

1. Begin with accurate diagnosis of menstrual migraine pattern using headache diary
2. For acute treatment: Start with NSAIDs; if ineffective, try triptans or combination therapy
3. If acute treatment alone is insufficient:
   • For predictable menstrual migraines: Add short-term prophylaxis
   • For frequent migraines throughout the cycle: Consider continuous preventive therapy
4. For women requiring contraception: Consider hormonal strategies that minimize estrogen fluctuation (except in migraine with aura)

Important Considerations

• Menstrual migraines are often more resistant to treatment than non-menstrual migraines 2
• Combination therapy (acute + preventive) is often more effective than either approach alone 2
• Monitor for medication overuse headache, defined as use of simple analgesics >15 days/month or triptans >10 days/month 1
• Evaluate treatment effectiveness after 2-3 months and adjust as needed 1
• Some anticonvulsants (particularly at higher doses) may reduce effectiveness of hormonal contraceptives 3

Lifestyle Modifications

Additional non-pharmacological approaches include:

• Regular sleep schedule
• Consistent meal times
• Adequate hydration
• Regular exercise program
• Stress management techniques 1