What are the treatment options for menstrual migraines?

Treatment Options for Menstrual Migraines

For menstrual migraines, perimenstrual preventive treatment with a long-acting NSAID (like naproxen) or triptan (like frovatriptan or naratriptan) for 5 days, beginning 2 days before expected menstruation, is the recommended approach when acute treatment alone is insufficient. 1

Understanding Menstrual Migraine

• Approximately 8% of women with migraine experience attacks exclusively related to menstruation (pure menstrual migraine), while a larger percentage experience menstrually-related migraines that occur both during menstruation and at other times 1, 2
• Menstrual migraines are typically more severe, longer-lasting, and more resistant to treatment than non-menstrual migraines 2, 3
• These migraines are triggered by estrogen withdrawal that occurs before menstruation 4, 5

Treatment Approach

Acute Treatment Options

1. First-line medications:

   • NSAIDs (acetylsalicylic acid, ibuprofen, diclofenac potassium) 1
   • These should be used early in the headache phase for maximum effectiveness 1

2. Second-line medications:

   • Triptans (sumatriptan, rizatriptan, eletriptan, etc.) 1
   • Rizatriptan has the best overall evidence for acute treatment of menstrual migraine with pain-free responses of 33-73% at 2 hours 2
   • Consider combining triptans with fast-acting NSAIDs to prevent recurrence 1

3. Adjunct medications:

   • Prokinetic antiemetics (domperidone, metoclopramide) for associated nausea/vomiting 1

4. Medications to avoid:

   • Oral ergot alkaloids (poorly effective and potentially toxic) 1
   • Opioids and barbiturates (questionable efficacy and risk of dependency) 1

Preventive Treatment Strategies

1. Perimenstrual prophylaxis (short-term prevention):

   • Long-acting NSAID (e.g., naproxen) taken daily for 5 days, beginning 2 days before expected menstruation 1
   • Long-acting triptan (e.g., frovatriptan 2.5mg twice daily or naratriptan 1mg twice daily) following the same schedule 1, 6, 3
   • This approach is particularly useful for women with pure menstrual migraine 1

2. Hormonal options:

   • Some women with pure menstrual migraine without aura benefit from continuous use (without a break) of combined hormonal contraceptives 1
   • IMPORTANT: Combined hormonal contraceptives are contraindicated in women with migraine with aura due to increased stroke risk 1, 5
   • Transcutaneous estradiol 1.5mg has shown efficacy for short-term prophylaxis 3

3. Standard preventive medications (if menstrual migraines are part of frequent migraines throughout the month):

   • First-line options: Beta-blockers (propranolol, metoprolol), candesartan, topiramate 1
   • Second-line options: Amitriptyline, flunarizine 1
   • Third-line options: OnabotulinumtoxinA, CGRP antagonists (erenumab, fremanezumab, eptinezumab) 1
   • Note: Sodium valproate is absolutely contraindicated in women of childbearing potential 1

Monitoring and Follow-up

• Evaluate treatment response within 2-3 months after initiation or change in treatment 1
• Use headache calendars to track attack frequency, severity, and medication use 1
• Consider the Migraine Treatment Optimization Questionnaire (mTOQ-4) to evaluate effectiveness of acute medications 1
• If one preventive treatment fails, try another drug class as failure of one does not predict failure of others 1

Special Considerations

• For women who also require contraception, consider contraceptive strategies that can simultaneously address menstrual migraine 3
• Be aware that some antiepileptic medications used for migraine prevention can affect the efficacy of oral contraceptives 2
• Topiramate has minimal effect on oral contraceptives at doses below 200 mg/day 2

Treatment Algorithm

1. Start with optimized acute treatment (NSAIDs first, then triptans if needed)
2. If menstrual migraines persist despite optimal acute treatment, add perimenstrual prophylaxis
3. For women with pure menstrual migraine without aura who need contraception, consider continuous combined hormonal contraceptives
4. For women with frequent migraines throughout the month, consider standard preventive medications
5. Regularly assess treatment effectiveness and adjust as needed