What are the treatment options for menstrual migraines?

Menstrual Migraine Treatment

Acute Treatment

For acute menstrual migraine attacks, use NSAIDs as first-line therapy early in the headache phase, with triptans as second-line agents that can be combined with NSAIDs to prevent recurrence. 1

First-Line Acute Medications

• NSAIDs (acetylsalicylic acid, ibuprofen, diclofenac potassium) should be initiated early in the headache phase for maximum effectiveness 1
• Mefenamic acid 500 mg has specific evidence for menstrual migraine 2

Second-Line Acute Medications

• Triptans are highly effective, with rizatriptan showing the best overall evidence: 33-73% pain-free at 2 hours and 63% sustained pain relief between 2-24 hours 3
• Sumatriptan 50-100 mg demonstrates 61-63% pain freedom at 2 hours 2, 3
• Rizatriptan 10 mg provides 32% sustained pain freedom between 2-24 hours 3
• Combination sumatriptan/naproxen 85 mg/500 mg has proven efficacy 2
• Triptans can be combined with fast-acting NSAIDs to prevent recurrence 1

Adjunct Therapy

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

Medications to Avoid

• Oral ergot alkaloids, opioids, and barbiturates should be avoided due to poor efficacy, potential toxicity, and dependency risk 1

Short-Term Perimenstrual Prophylaxis

When acute treatment alone is insufficient, initiate perimenstrual prophylaxis with frovatriptan 2.5 mg twice daily or naratriptan 1 mg twice daily for 5-6 days, beginning 2 days before expected menstruation. 1, 4

Triptan Prophylaxis (Preferred)

• Frovatriptan 2.5 mg twice daily is the mainstay of short-term prevention with the strongest evidence 4, 2
• Frovatriptan shows superior efficacy compared to transdermal estrogen and naproxen sodium, with lower daily migraine incidence (median headache severity score 2.5 vs. 3.0 vs. 3.9 respectively, p=0.049) 5
• Naratriptan 1 mg twice daily has grade B evidence for perimenstrual prophylaxis 2
• Zolmitriptan three times daily also shows efficacy 3
• Treatment duration: 5-6 days total, starting 2 days before expected menstruation 1, 4

NSAID Prophylaxis (Alternative)

• Long-acting NSAIDs like naproxen sodium 500 mg once daily can be used for the same 5-6 day perimenstrual window 1, 2
• Naproxen appears less effective than frovatriptan based on comparative data 5

Hormonal Prophylaxis

• Transdermal estradiol 1.5 mg has grade B evidence but appears less effective than frovatriptan 5, 2

Daily Preventive Treatment

For women with frequent migraines throughout the month (not just menstrually-related), use standard daily preventive medications such as beta-blockers, candesartan, or topiramate. 1

When to Use Daily Prevention

• Women experiencing migraine attacks both during menstruation and at other times of the cycle 4
• When short-term prophylaxis is insufficient 1

Medication Options

• Beta-blockers (propranolol is preferred if pregnancy is a consideration) 1
• Candesartan 1
• Topiramate (note: contraindicated in pregnancy and can affect oral contraceptive efficacy at doses >200 mg/day) 1, 3

Hormonal Contraceptive Strategies

Continuous use of combined hormonal contraceptives can benefit women with pure menstrual migraine without aura, but are absolutely contraindicated in women with migraine with aura due to increased stroke risk. 1

• Extended-dosing strategies with oral contraceptives may prevent menstrual migraine 6
• This approach is only appropriate for women requiring contraception who have migraine without aura 1

Monitoring and Treatment Optimization

• 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 acute medication effectiveness 1
• If one preventive treatment fails, try another drug class—failure of one does not predict failure of others 1

Critical Clinical Pitfalls

• Menstrual migraine attacks are typically longer, more severe, and less responsive to treatment than non-menstrual attacks, so aggressive early treatment is essential 4, 2, 3
• Avoid medication overuse: limit NSAIDs to <15 days/month and triptans to <10 days/month to prevent medication overuse headache 7
• Do not use triptans within 24 hours of ergot-type medications 8
• Be aware that antiepileptic preventive medications can reduce oral contraceptive efficacy, particularly lamotrigine (though topiramate has minimal effect at <200 mg/day) 3