Treatment of Menstrual Migraine
For menstrual migraine, start with NSAIDs (ibuprofen 400-800mg or naproxen 275-550mg) or triptans (rizatriptan 10mg, sumatriptan 50-100mg) as acute therapy, and if attacks remain disabling despite optimal acute treatment, add perimenstrual prophylaxis with frovatriptan 2.5mg twice daily or naratriptan 1mg twice daily starting 2 days before expected menstruation for 5 days. 1
Acute Treatment Approach
First-Line Acute Therapy
- NSAIDs are the initial treatment for mild-to-moderate menstrual migraine attacks 2
- Take NSAIDs early when headache is still mild for maximum effectiveness 1
- NSAIDs are particularly appropriate when dysmenorrhea coexists, as prostaglandins play a role in both conditions 3
Second-Line Acute Therapy
- Triptans should be used when NSAIDs provide inadequate relief 2, 1
- Rizatriptan 10mg has the strongest evidence for acute menstrual migraine treatment, with pain-free responses of 33-73% at 2 hours and sustained pain relief of 63% between 2-24 hours 4
- Sumatriptan 50-100mg is equally effective (50mg and 100mg show no significant difference in efficacy) 5, 6
- Combination sumatriptan 85mg/naproxen 500mg prevents recurrence better than either alone 1, 6
- Take triptans early when headache is mild, not during aura phase 2
Adjunctive Therapy
- Metoclopramide or prochlorperazine for nausea/vomiting 2, 1
- Avoid opioids and barbiturates due to dependency risk, rebound headaches, and poor efficacy 2, 1
Perimenstrual Prophylaxis (Short-Term Prevention)
Indications: When acute treatment alone is insufficient to control disability from predictable menstrual attacks 1, 3
Triptan-Based Prophylaxis
- Frovatriptan 2.5mg twice daily for 6 days (starting 2 days before expected menstruation) has the most robust evidence with four randomized controlled trials 1, 4
- Naratriptan 1mg twice daily for 5-6 days (starting 2 days before menses) 1, 6, 4
- Zolmitriptan 2.5mg three times daily 4
- This approach can reduce headache frequency by approximately 50% 3
NSAID-Based Prophylaxis
- Naproxen sodium 550mg twice daily starting 2 days before expected menstruation for 5 days 1
- Mefenamic acid 500mg 6
- Particularly useful when hormonal strategies are contraindicated 3
Hormonal Prophylaxis
- Transcutaneous estradiol 1.5mg daily (gel or patch) applied perimenstrually has grade B evidence for women with pure menstrual migraine 2, 6
- Continuous combined hormonal contraceptives (extended-dosing strategy) can reduce hormone fluctuations and benefit women with pure menstrual migraine without aura 1, 3, 7
- Contraindicated in migraine with aura due to increased stroke risk 1
Daily Preventive Therapy
When migraines occur frequently throughout the month, not just menstrually 1
- Beta-blockers (propranolol 120-240mg daily) 2, 1
- Candesartan 1
- Topiramate (has least effect on oral contraceptives at doses <200mg/day) 4
- Avoid combining antiepileptic preventives with hormonal treatments due to enzyme induction affecting contraceptive efficacy 4
Treatment Selection Algorithm
- Determine attack pattern: Use 3-month headache diary to confirm predictable menstrual relationship 8
- Start with acute therapy: NSAIDs for mild-moderate attacks; triptans for moderate-severe or NSAID-refractory attacks 1
- Evaluate response at 2-3 months using headache calendars and mTOQ-4 questionnaire 1
- Add perimenstrual prophylaxis if:
- Consider daily prevention if:
Critical Pitfalls
- Do not use triptans during aura phase - they are ineffective and should only be used when headache begins 2
- Do not prescribe hormonal contraceptives to women with migraine with aura - stroke risk is significantly elevated 1
- Monitor for medication overuse - limit triptan use and educate patients on rebound headache risk 2
- Ensure adequate trial duration - perimenstrual prophylaxis requires at least 2-3 menstrual cycles to assess efficacy 1
- Account for drug interactions - antiepileptic preventives (except topiramate <200mg/day) significantly reduce oral contraceptive efficacy 4