What are the acute and preventive treatments for menstrual migraine?

Menstrual Migraine: Acute and Preventive Treatment

Acute Treatment Strategy

Start with NSAIDs for mild-to-moderate menstrual migraine attacks, escalating to triptans when NSAIDs provide inadequate relief, with sumatriptan and rizatriptan being the most effective options. 1, 2

First-Line Acute Treatment: NSAIDs

• Administer NSAIDs early when headache is still mild in severity to maximize effectiveness 1, 2
• Effective options include:
  • Ibuprofen 400-800mg every 6 hours 1, 2
  • Naproxen sodium 275-550mg every 2-6 hours 1, 2
  • Diclofenac potassium 1

Second-Line Acute Treatment: Triptans

• Escalate to triptans when NSAIDs provide inadequate relief 1, 2
• Most effective options based on evidence:
  • Sumatriptan 50-100mg provides 61-78% headache response at 4 hours 3, 4, 5
  • Rizatriptan 10mg demonstrates 63% sustained pain relief between 2-24 hours and 32% sustained pain freedom 1, 2, 5
  • Combination sumatriptan/naproxen 85mg/500mg is also highly effective 2
• Never use triptans during the aura phase—they are ineffective and should only be used when headache begins 1, 2

Adjunct Therapy

• Prokinetic antiemetics (domperidone, metoclopramide) can be used for associated nausea and vomiting 1, 2

Critical Pitfalls in Acute Treatment

• 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, 2
• Monitor for medication overuse—limit triptan use and educate patients on rebound headache risk 1, 2

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Preventive Treatment Strategy

For women with menstrual migraine inadequately controlled by acute treatment alone, implement perimenstrual prophylaxis with frovatriptan 2.5mg twice daily starting 2 days before expected menstruation and continuing for 5-6 days. 1, 2

Short-Term Perimenstrual Prophylaxis

This approach is ideal for women with pure menstrual migraine (attacks only during menstruation) or predictable menstrually-related attacks. 1, 6

First-Line: Frovatriptan

• Frovatriptan 2.5mg twice daily is the mainstay of short-term prevention 2, 5, 6
• Start 2 days before expected menstruation and continue for 5-6 days 1, 2
• Frovatriptan demonstrates superior effectiveness compared to transdermal estrogen and naproxen sodium in reducing daily incidence and severity of menstrual migraine 7
• Frovatriptan is particularly effective in preventing headache recurrence 4

Alternative Short-Term Options

• Naratriptan 1mg twice daily using the same timing (2 days before menstruation for 5-6 days) 1, 2, 5
• Long-acting NSAIDs like naproxen for 5 days beginning 2 days before expected menstruation 1, 2
• Zolmitriptan three times daily has shown statistically significant results 5

Daily Preventive Therapy

Use daily preventive medications for women with frequent migraines throughout the month, not just during menstruation. 1, 2

First-Line Daily Preventives

• Beta-blockers (propranolol 120-240mg daily, metoprolol, atenolol, bisoprolol) 1, 2
• Topiramate 50-100mg daily 2
• Candesartan 2

Emerging Options

• CGRP monoclonal antibodies (erenumab, galcanezumab) are more effective than triptans in reducing monthly headache days 4
• These represent newer options for women requiring daily prevention 4

Hormonal Strategies

Continuous use of combined hormonal contraceptives can benefit women with pure menstrual migraine without aura by eliminating the hormone-free interval. 1, 2

Critical Contraindication

• Absolutely contraindicated in women with migraine with aura due to increased stroke risk 1, 2
• Transcutaneous estradiol 1.5mg daily (gel or patch) applied perimenstrually has grade B evidence for women with pure menstrual migraine 1

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Treatment Selection Algorithm

Step 1: Assess Migraine Pattern

• Pure menstrual migraine (attacks only during menstruation): Consider perimenstrual prophylaxis 1, 6
• Menstrually-related migraine (attacks during and outside menstruation): Consider daily preventive therapy 1, 2

Step 2: Initial Acute Treatment Trial

• Start all patients with NSAIDs as first-line acute treatment 1, 2
• If inadequate response, escalate to triptans (sumatriptan or rizatriptan preferred) 1, 2, 5

Step 3: Add Preventive Treatment if Needed

• If acute treatment alone is insufficient, implement perimenstrual prophylaxis with frovatriptan 1, 2, 6
• If migraines occur frequently throughout the month, implement daily preventive therapy with beta-blockers, topiramate, or candesartan 1, 2

Step 4: Consider Hormonal Strategies

• Only in women with pure menstrual migraine without aura, consider continuous combined hormonal contraceptives 1, 2
• Never use in women with migraine with aura 1, 2

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Monitoring and Follow-Up

• 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, 2
• If one preventive treatment fails, try another drug class as failure of one does not predict failure of others 1, 2

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Key Clinical Pearls

• Menstrual migraine attacks are typically more severe, longer lasting, and more resistant to treatment than non-menstrual attacks 8, 5, 6
• Approximately 8% of women with migraine experience pure menstrual migraine, while a larger percentage experience menstrually-related migraines 1
• The combination of acute treatment optimization plus perimenstrual prophylaxis provides the best outcomes for most women with menstrual migraine 1, 2, 6