What are the treatment options for symptoms like headache, eye twitching, cramping, menstrual bleeding, and neck pain associated with menstrual migraines or premenstrual syndrome (PMS)?

Treatment Options for Menstrual Migraines and PMS Symptoms

For menstrual migraines and associated symptoms like headache, eye twitching, cramping, menstrual bleeding, and neck pain, a combination of acute treatment and preventive strategies is recommended, with NSAIDs and triptans being the most effective options.

Acute Treatment Options

First-line Medications

• NSAIDs (acetylsalicylic acid, ibuprofen, or diclofenac potassium) are recommended as first-line treatment for mild to moderate menstrual migraines 1
• For menstrual migraine specifically, naproxen sodium has shown effectiveness for both acute treatment and short-term prevention 2, 3

Second-line Medications

• Triptans are recommended for moderate to severe migraines or when NSAIDs provide insufficient relief 1
• Rizatriptan has the best overall evidence for acute treatment of menstrual migraine, with pain-free responses of 33-73% at 2 hours 4
• Sumatriptan (50-100mg) has also shown good efficacy for menstrual migraine attacks 4, 2
• Combination therapy of sumatriptan/naproxen (85mg/500mg) has demonstrated effectiveness specifically for menstrual migraine 2

For Associated Symptoms

• Metoclopramide can be used to treat the nausea that often accompanies menstrual migraines 1
• For neck pain and cramping, NSAIDs provide dual benefit by addressing both pain and menstrual symptoms 1, 3

Short-term Preventive Treatment

Perimenstrual preventive treatment is highly effective for menstrual migraines and should be considered for predictable attacks.

• Daily intake of a long-acting NSAID (e.g., naproxen) for 5 days, beginning 2 days before expected menstruation 1
• Triptans with longer half-lives have shown effectiveness for short-term prevention:
  • Frovatriptan 2.5mg twice daily 4, 2
  • Naratriptan 1mg twice daily 4, 2
  • Zolmitriptan three times daily 4

Long-term Preventive Options

For women with frequent and severe menstrual migraines, consider these preventive medications:

First-line Preventive Medications

• Beta-blockers (atenolol, bisoprolol, metoprolol, propranolol) 1
• Candesartan 16-32mg daily (avoid in women of childbearing potential) 1

Second-line Preventive Medications

• Amitriptyline 10-100mg at night 1
• Topiramate 50-100mg daily (contraindicated in pregnancy) 1

Hormonal Options

• Some women with pure menstrual migraine without aura may benefit from continuous use of combined hormonal contraceptives 1
• Important caveat: Combined hormonal contraceptives are contraindicated in women with migraine with aura due to increased stroke risk 1

Special Considerations

Medication Overuse Risk

• Limit use of acute medications to avoid medication overuse headache (≤10 days/month for triptans, ≤15 days/month for NSAIDs) 5
• Medication overuse can lead to chronic daily headaches or increased frequency of attacks 5

Safety Precautions with Triptans

• Triptans are contraindicated in patients with:
  • Coronary artery disease or vasospasm 5
  • History of stroke or TIA 5
  • Uncontrolled hypertension 5
  • Recent use (within 24 hours) of another triptan or ergotamine-containing medication 5

During Pregnancy

• Paracetamol (acetaminophen) is the first-line medication for migraine during pregnancy 6
• NSAIDs should only be used in the second trimester if necessary 6
• Most preventive medications should be avoided during pregnancy 6

Non-Pharmacological Approaches

• Identify and avoid migraine triggers 1
• Maintain regular sleep patterns, meals, and hydration 1
• Regular physical activity can help reduce frequency and severity of attacks 1

Treatment Algorithm for Menstrual Migraine

1. For mild attacks: Start with NSAIDs (ibuprofen 400-600mg or naproxen 500mg) at first sign of headache 1
2. For moderate-severe attacks: Use a triptan (rizatriptan 10mg or sumatriptan 50-100mg) 4, 2
3. For predictable menstrual attacks: Implement short-term prevention with naproxen or a long-acting triptan (frovatriptan or naratriptan) starting 2 days before expected menstruation 1, 2
4. For frequent, disabling attacks: Consider continuous preventive therapy with a beta-blocker or topiramate 1