What are the treatment options for menstrual migraines?

Treatment of Menstrual Migraine

For menstrual migraines, start with NSAIDs (ibuprofen, naproxen, or diclofenac) or triptans as acute treatment, and if attacks remain disabling despite acute therapy, add perimenstrual prophylaxis with frovatriptan 2.5mg twice daily or naproxen starting 2 days before expected menstruation for 5-6 days. 1

Acute Treatment Strategy

First-Line Acute Medications

• NSAIDs are the initial choice for acute menstrual migraine attacks, with acetylsalicylic acid, ibuprofen, and diclofenac potassium having the strongest evidence 2, 1
• Take these medications early when headache is still mild for maximum effectiveness 1
• Paracetamol should only be used if NSAIDs are not tolerated due to inferior efficacy 2

Second-Line Acute Medications

• Triptans should be offered when NSAIDs provide inadequate relief 2, 1
• Among triptans, rizatriptan demonstrates the best overall acute treatment evidence with pain-free responses of 33-73% at 2 hours and sustained pain relief of 63% between 2-24 hours 3
• Sumatriptan 50-100mg shows 52-62% headache response at 2 hours and 65-79% at 4 hours, with no additional benefit above 50mg 4
• Take triptans early when headache is mild, not during aura phase 2
• If one triptan fails, try another as individual responses vary 2

Adjunct Medications

• Prokinetic antiemetics (domperidone, metoclopramide) can be added for nausea and vomiting 1

Medications to Avoid

• Do not use oral ergot alkaloids, opioids, or barbiturates due to poor efficacy and risk of dependency 1

Perimenstrual Prophylaxis (Short-Term Prevention)

This approach is specifically recommended by the American Academy of Neurology when acute treatment alone is insufficient 1

When to Use Short-Term Prevention

• Pure menstrual migraine (attacks only during menstruation) that is inadequately controlled with acute treatment alone 1, 5
• Menstrual attacks that are predictably severe, prolonged, or resistant to acute therapy 5, 6

Triptan-Based Prophylaxis

• Frovatriptan 2.5mg twice daily is the mainstay and preferred triptan for short-term prevention based on overall efficacy 1, 5, 7, 3
• Naratriptan 1mg twice daily is an alternative 1, 3
• Zolmitriptan three times daily has shown efficacy but is less convenient 3
• Start 2 days before expected menstruation and continue for 5-6 days 1, 5

NSAID-Based Prophylaxis

• Long-acting NSAIDs like naproxen can be used for perimenstrual prophylaxis 1, 3
• Follow the same 5-day regimen starting 2 days before expected menstruation 1
• Particularly useful when dysmenorrhea coexists 8

Important Caveat

• Risk of medication overuse headache exists if the patient actually has menstrually-related migraine (attacks both during and outside menstruation) but is being treated as pure menstrual migraine 7
• Overuse of acute migraine drugs for ≥10 days per month can lead to medication overuse headache 4

Daily Preventive Treatment

When to Use Daily Prevention

• Women with menstrually-related migraine (attacks during menstruation AND at other times of the month) 1, 7
• Women with severe pure menstrual migraine unresponsive to short-term prophylaxis 7
• Frequent attacks throughout the menstrual cycle 1

Medication Options

• Standard migraine preventives: beta-blockers, candesartan, topiramate 1
• Continuous combined hormonal contraceptives can benefit women with pure menstrual migraine without aura 1, 7
• Contraindication: Hormonal contraceptives are contraindicated in migraine with aura due to increased stroke risk 1, 7

Antiepileptic Drug Considerations

• Many antiepileptic drugs used for migraine prevention can reduce oral contraceptive efficacy 3
• Topiramate has the least effect on oral contraceptives at doses below 200mg/day 3
• Exercise caution when combining these medication classes 3

Monitoring and Treatment Optimization

• Evaluate treatment response within 2-3 months after initiation or change 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 fails, try another drug class as failure of one does not predict failure of others 1

Clinical Pearls

• Menstrual migraine attacks are typically longer, more severe, and more resistant to treatment than non-menstrual attacks 5, 6
• The predictable timing of pure menstrual migraine makes short-term prophylaxis particularly effective 8
• Menstruation is one of the few truly important trigger factors in migraine, unlike many overemphasized triggers 2
• Approximately 8% of women with migraine have pure menstrual migraine, while a larger percentage have menstrually-related migraine 1