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

Treatment of Menstrual Migraines

For menstrual migraines, start with NSAIDs (ibuprofen 400-800mg or naproxen 275-550mg) for acute attacks, and if attacks remain disabling despite acute treatment, add perimenstrual prophylaxis with naproxen or a long-acting triptan (frovatriptan 2.5mg twice daily or naratriptan 1mg twice daily) for 5 days starting 2 days before expected menstruation. 1, 2

Initial Diagnostic Steps

• Have the patient maintain a headache calendar for at least 3 months to document the temporal relationship between migraines and menstruation, recording headache frequency, intensity, associated symptoms (nausea, photophobia, phonophobia), and medication use 3
• Ask specifically about the timing of attacks relative to menstruation, as approximately 50% of women with migraine experience increased attacks during their menstrual period 2
• Distinguish between pure menstrual migraine (attacks exclusively during menstruation, affecting ~8% of women with migraine) and menstrually-related migraine (attacks both during menstruation and at other times) 1, 2

Acute Treatment Algorithm

First-Line: NSAIDs

• Start with NSAIDs as initial acute treatment: ibuprofen 400-800mg every 6 hours or naproxen sodium 275-550mg every 2-6 hours 1, 2
• Acetylsalicylic acid and diclofenac potassium also have strong evidence 1, 2
• Instruct the patient to take medication early in the attack when headache is still mild for maximum effectiveness 1

Second-Line: Triptans

• Use triptans when NSAIDs provide inadequate relief: sumatriptan 50-100mg or rizatriptan 10mg 1, 2
• Triptans can be combined with fast-acting NSAIDs to prevent recurrence 1
• Critical pitfall: Never use triptans during the aura phase—they are ineffective and should only be used when the headache begins 1

Adjunct Therapy

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

Medications to Avoid

• Do not prescribe opioids, barbiturates, or oral ergot alkaloids due to poor efficacy, dependency risk, and potential toxicity 1, 2

Perimenstrual Prophylaxis (When Acute Treatment Alone Is Insufficient)

This is the key intervention for menstrual migraines that remain disabling despite optimized acute treatment.

Medication Options

• Long-acting NSAID: Naproxen taken daily for 5 days, beginning 2 days before expected menstruation 1, 4, 2
• Long-acting triptan: Frovatriptan 2.5mg twice daily OR naratriptan 1mg twice daily for 5 days, beginning 2 days before expected menstruation 1, 4, 2
• Transcutaneous estradiol 1.5mg daily (gel or patch) applied perimenstrually has grade B evidence for women with pure menstrual migraine 1, 2

Important Considerations

• This approach is specifically recommended by the American Academy of Neurology and European Headache Federation 2
• The timing is critical: start 2 days before the expected first day of menstruation 1, 4, 2
• Monitor for medication overuse and educate patients about rebound headache risk with frequent triptan use 1

Hormonal Approaches (For Pure Menstrual Migraine Without Aura Only)

• Continuous use of combined hormonal contraceptives can benefit women with pure menstrual migraine without aura by avoiding the estrogen drop that triggers attacks 1, 4
• Absolute contraindication: Combined hormonal contraceptives are contraindicated in women with migraine with aura due to increased stroke risk 1, 4

Daily Preventive Therapy (For Frequent Migraines Throughout the Month)

If the patient has frequent migraines beyond just the menstrual period (more than 2 attacks per week), consider standard preventive medications:

First-Line Options

• Beta-blockers: Propranolol 120-240mg daily, metoprolol 50-100mg twice daily, atenolol 25-100mg twice daily, or bisoprolol 5-10mg daily 1, 4, 5
• Candesartan: 16-32mg daily 4
• Topiramate: 50-100mg daily 4

Second-Line Options

• Amitriptyline: 10-100mg at night 4
• Flunarizina: 5-10mg daily 4

Contraindications to Note

• Beta-blockers are contraindicated in asthma, heart failure, Raynaud's disease, AV block, or depression 4
• Valproic acid is absolutely contraindicated in women of childbearing age 4
• Topiramate is contraindicated in nephrolithiasis, pregnancy, lactation, and glaucoma 4

Monitoring and Follow-Up

• Evaluate treatment response within 2-3 months after initiation or change in treatment 1
• Continue using headache calendars to track attack frequency, severity, and medication use 1, 4
• If one preventive treatment fails, try another drug class—failure of one does not predict failure of others 1

Special Populations

Pregnancy

• Paracetamol (acetaminophen) is first-line during pregnancy despite relatively poor efficacy 2
• NSAIDs can only be used during the second trimester 2

Breastfeeding

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