What is the recommended approach for managing menstrual migraine?

Management of Menstrual Migraine

For menstrual migraine, start with early acute treatment using NSAIDs or triptans, and if attacks remain disabling despite optimal acute therapy, add perimenstrual prophylaxis with frovatriptan 2.5mg twice daily or naratriptan 1mg twice daily starting 2 days before expected menstruation for 5-6 days. 1

Acute Treatment Strategy

First-Line Acute Therapy

• Use NSAIDs as initial treatment for mild-to-moderate menstrual migraine attacks, with ibuprofen 400-800mg every 6 hours, naproxen sodium 275-550mg every 2-6 hours, or diclofenac potassium as effective options 1, 2
• Acetaminophen has limited efficacy and should only be used in patients intolerant to NSAIDs 3, 2
• Administer acute therapy early when headache is still mild in severity to maximize effectiveness 1, 4

Second-Line Acute Therapy

• Escalate to triptans when NSAIDs provide inadequate relief, with sumatriptan 50-100mg, rizatriptan 10mg, or combination sumatriptan/naproxen 85mg/500mg as proven effective options 1, 5
• The 50mg and 100mg doses of sumatriptan provide greater effect than 25mg, but 100mg may not provide additional benefit over 50mg 6
• If migraine persists or returns after 2 hours, a second dose may be administered at least 2 hours after the first dose, with maximum daily dose of 200mg 6
• Never use triptans during the aura phase—they are ineffective and should only be used when headache begins 1

Medications to Avoid

• Avoid opioids and barbiturates due to dependency risk, rebound headaches, and poor efficacy 1, 2
• Avoid oral ergot alkaloids due to poor efficacy and potential toxicity 1

Perimenstrual Prophylaxis (Short-Term Prevention)

When to Consider

• Implement perimenstrual prophylaxis when acute treatment alone is insufficient to control menstrual migraine attacks 1
• This approach is particularly effective for women with pure menstrual migraine (attacks occurring exclusively with menstruation) 1, 7
• Requires predictable menstrual cycles—use headache diaries for 3 complete cycles to accurately predict onset 4, 8

Recommended Regimens

• Frovatriptan 2.5mg twice daily is the mainstay of short-term prevention, started 2 days before expected menstruation and continued for 5-6 days 1, 5, 7
• Naratriptan 1mg twice daily using the same timing is an alternative option 1, 5
• Long-acting NSAIDs like naproxen can also be used perimenstrually for 5 days beginning 2 days before expected menstruation 1, 2
• Transcutaneous estradiol 1.5mg daily (gel or patch) applied perimenstrually has grade B evidence for women with pure menstrual migraine 1, 5

Daily Preventive Therapy

When to Consider

• Use daily preventive medications for women with frequent migraines throughout the month, not just during menstruation 1, 2
• Consider when perimenstrual prophylaxis alone is insufficient or when attacks occur at other times of the cycle 7

Recommended Options

• Beta-blockers (propranolol 120-240mg daily, metoprolol, atenolol, bisoprolol) as first-line daily preventive therapy 1, 2
• Topiramate 50-100mg daily as an alternative first-line option 2
• Candesartan as another first-line choice 1

Hormonal Strategies

Combined Hormonal Contraceptives

• Continuous use of combined hormonal contraceptives can benefit women with pure menstrual migraine without aura by eliminating the hormone-free interval 1, 2
• Absolutely contraindicated in women with migraine with aura due to increased stroke risk 1, 2
• Only consider in appropriately selected patients who also require contraception 5, 7

Adjunct Therapy

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

Monitoring and Follow-Up

Treatment Evaluation

• Evaluate treatment response within 2-3 months after initiation or change in treatment 1, 2
• Use headache calendars to track attack frequency, severity, and medication use 1, 2
• Consider the Migraine Treatment Optimization Questionnaire (mTOQ-4) to evaluate effectiveness of acute medications 1

Critical Pitfalls to Avoid

• Monitor for medication overuse—limit triptan use and educate patients on rebound headache risk 1
• Do not treat more than 4 headaches per 30-day period on average with triptans, as safety beyond this has not been established 6
• Recognize that menstrual attacks are typically more severe, longer in duration, less responsive to treatment, and more likely to relapse than non-menstrual attacks 5, 7
• If one preventive treatment fails, try another drug class as failure of one does not predict failure of others 1

Hepatic Impairment Consideration

• In patients with mild to moderate hepatic impairment, maximum single dose of sumatriptan should not exceed 50mg 6