What are the treatment options for a female patient experiencing menstrual migraines?

Treatment of Menstrual Migraine

For women with menstrual migraines, start with NSAIDs (ibuprofen, naproxen, or diclofenac) as first-line acute treatment, escalate to triptans if NSAIDs fail, and implement perimenstrual prophylaxis with frovatriptan 2.5mg twice daily or naproxen for 5 days (starting 2 days before expected menstruation) when acute treatment alone proves insufficient. 1, 2

Acute Treatment Algorithm

First-Line: NSAIDs

• Use NSAIDs as initial therapy for all menstrual migraine attacks, including acetylsalicylic acid, ibuprofen 400-800mg every 6 hours, naproxen sodium 275-550mg every 2-6 hours, or diclofenac potassium 3, 1, 2
• Administer early when headache is still mild for maximum effectiveness 1

Second-Line: Triptans

• Switch to triptans when NSAIDs provide inadequate relief 3, 1
• Rizatriptan 10mg has the strongest evidence for acute 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, with 61-63% achieving 2-hour pain freedom 5, 4
• Combine triptans with fast-acting NSAIDs to prevent recurrence when triptans alone provide insufficient relief 3, 1

Adjunct Therapy

• Add prokinetic antiemetics (domperidone or metoclopramide) for associated nausea and vomiting 1

Medications to Avoid

• Never use opioids or 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)

This approach is specifically for women with predictable menstrual cycles when acute treatment alone is insufficient. 1, 2

Triptan-Based Prophylaxis (Preferred)

• Frovatriptan 2.5mg twice daily is the triptan of choice based on overall efficacy, taken for 5 days beginning 2 days before expected menstruation 1, 6, 7, 4
• Alternative: Naratriptan 1mg twice daily for the same 5-day perimenstrual window 1, 4
• Alternative: Zolmitriptan three times daily (though less convenient dosing) 4

NSAID-Based Prophylaxis

• Long-acting naproxen or naproxen sodium for 5 days, starting 2 days before expected menstruation 1, 2
• This approach has modest but statistically significant effects on headache frequency 2

Hormonal Prophylaxis

• Transcutaneous estradiol 1.5mg daily (gel or patch) applied perimenstrually has grade B evidence for women with pure menstrual migraine 1, 2
• This benefit is specific to menstruation-related migraines and does not extend to non-menstrual attacks 2

Daily Preventive Therapy

Reserve for women with frequent migraines throughout the month (menstrually-related migraine) or severe pure menstrual migraine unresponsive to perimenstrual prophylaxis. 1, 7

Standard Preventive Options

• Beta-blockers (propranolol 120-240mg daily) 1
• Candesartan 1
• Topiramate (note: doses below 200mg/day have minimal effect on oral contraceptives) 1, 4

Hormonal Contraceptive Approach

• Continuous combined hormonal contraceptives can benefit women with pure menstrual migraine WITHOUT aura 1
• Absolutely contraindicated in women with migraine WITH aura due to increased stroke risk 1, 7

Critical Pitfalls to Avoid

• Never administer triptans during the aura phase—they are ineffective and should only be used when headache begins 1
• Monitor for medication overuse headache—limit triptan use and educate patients about rebound risk 1
• Risk of medication overuse is particularly high when treating menstrually-related migraine (attacks throughout the cycle) with perimenstrual prophylaxis intended for pure menstrual migraine 7
• Avoid sodium valproate in all women of childbearing potential 3
• Many antiepileptic preventive medications induce enzymes that reduce oral contraceptive efficacy; topiramate has the least effect at doses below 200mg/day, while lamotrigine noticeably decreases contraceptive levels 4

Monitoring and Follow-Up

• Use headache calendars to prospectively document headache days, severity, and relationship to menstruation for accurate diagnosis and treatment planning 1, 8
• Track through three complete menstrual cycles to predict onset and guide timing of perimenstrual prophylaxis 9
• Evaluate treatment response within 2-3 months after initiation or change 1
• Consider the Migraine Treatment Optimization Questionnaire (mTOQ-4) to evaluate acute medication effectiveness 1
• If one preventive fails, try another drug class—failure of one does not predict failure of others 1

Special Population Considerations

Pregnancy

• Use paracetamol (acetaminophen) as first-line despite relatively poor efficacy 3, 2
• NSAIDs only permitted during second trimester 2

Breastfeeding

• Paracetamol preferred, though ibuprofen and sumatriptan are considered safe 2