What are the treatment options for menstrual migraines?

Treatment Options for Menstrual Migraines

Menstrual migraines should be treated with a combination of acute medications (triptans with NSAIDs) for attacks and short-term preventive therapy (frovatriptan 2.5mg twice daily) during the perimenstrual period for optimal management of these particularly severe and treatment-resistant headaches. 1, 2, 3

Understanding Menstrual Migraines

Menstrual migraines are classified into two categories:

• Pure menstrual migraine: Attacks occur exclusively on day 1 ± 2 of menstruation in at least 2 out of 3 menstrual cycles (prevalence ~1%) 4
• Menstrually-related migraine: Attacks occur during menstruation but also at other times in the cycle (prevalence ~6-7%) 4

These migraines are typically more severe, longer-lasting, and more resistant to treatment than non-menstrual migraines due to hormonal fluctuations, particularly estrogen withdrawal 5, 3.

Treatment Algorithm

1. Acute Treatment Options

First-line acute treatments for menstrual migraines include:

• Triptans + NSAIDs combination (most effective approach for moderate to severe attacks) 1

  • Triptans options:
    • Sumatriptan 50-100mg
    • Rizatriptan 10mg (strongest evidence for acute treatment with 33-73% pain-free response at 2 hours) 3
    • Zolmitriptan
    • Naratriptan
    • Frovatriptan 2.5mg (note: may be preferred in elderly patients due to longer half-life) 6

• NSAIDs options:

  • Naproxen sodium
  • Mefenamic acid 500mg
  • Ibuprofen
  • Aspirin 650-1000mg 1

• Other effective options:

  • Combination of acetaminophen + aspirin + caffeine 1, 5
  • Antiemetics (e.g., metoclopramide IV) when nausea/vomiting present 1

2. Preventive Treatment Approaches

Short-term Perimenstrual Prophylaxis

For women with predictable menstrual attacks:

• Triptans (start 2 days before expected headache):

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

• Non-triptan options:

  • Naproxen sodium 3
  • Magnesium supplementation 3
  • Transcutaneous estradiol 1.5mg (addresses estrogen withdrawal trigger) 2

Daily Preventive Medications

For women with frequent or severe menstrual migraines:

• First-line preventives (per American Academy of Neurology) 1:
  • Beta-blockers: Propranolol (80-240mg/day) or Timolol (20-30mg/day)
  • Anticonvulsants: Topiramate (100mg/day) - strongest evidence for chronic migraine
  • Antidepressants: Amitriptyline (30-150mg/day)

3. Hormonal Strategies

For women with severe menstrual migraines not controlled by other treatments:

• Continuous combined hormonal contraceptives with no placebo pills or only 2 days of placebo to avoid estrogen withdrawal 4
  • Important caveat: Contraindicated in women with migraine with aura due to increased stroke risk 4

Special Considerations

• Medication interactions: Many antiepileptic medications used for migraine prevention can affect the efficacy of oral contraceptives. Topiramate has minimal effect at doses below 200mg/day 3

• Treatment evaluation: Evaluate effectiveness after 2-3 months; consider changing medication if inadequate response 1

• Lifestyle modifications: Regular sleep schedule, consistent meal times, adequate hydration, and regular exercise program are recommended as adjunctive therapy 1

• Headache diary: Essential for tracking menstrual correlation, treatment response, and identifying medication overuse 1

Menstrual migraines require targeted therapy due to their severity and resistance to standard treatments. The combination of acute medications with short-term prophylaxis during the perimenstrual period offers the most effective management strategy for most women with this condition.