What is the best treatment approach for a female patient experiencing menstrual migraines?

Treatment of Menstrual Migraine

For women with menstrual migraine, start with NSAIDs (ibuprofen 400-800mg or naproxen 500-550mg) as first-line acute treatment, and if attacks remain disabling despite optimized acute therapy, add perimenstrual prophylaxis with frovatriptan 2.5mg twice daily or naratriptan 1mg twice daily for 5 days starting 2 days before expected menstruation. 1, 2

Acute Treatment Strategy

First-Line: NSAIDs

• Use NSAIDs as initial therapy for all menstrual migraine attacks, with the strongest evidence supporting ibuprofen (400-800mg every 6 hours), naproxen sodium (275-550mg every 2-6 hours), acetylsalicylic acid, or diclofenac potassium 3, 1, 2
• Take medication early when headache is still mild for maximum effectiveness 1, 4

Second-Line: Triptans

• Escalate to triptans when NSAIDs provide inadequate relief 3, 1
• For acute treatment, rizatriptan 10mg has the best overall evidence with 2-hour pain freedom rates of 33-73% and sustained pain relief of 63% between 2-24 hours 5
• Sumatriptan 50-100mg is equally effective with 61-63% pain freedom at 2 hours 6, 5
• Combine triptans with fast-acting NSAIDs to prevent recurrence 1

Critical Timing Consideration

• Never use triptans during aura phase—they are ineffective and should only be taken when headache begins 1

Perimenstrual Prophylaxis (Short-Term Prevention)

When to Initiate

• Consider prophylaxis when optimized acute treatment alone is insufficient and periods are predictable 1, 2, 7
• Requires prospective headache diary documentation through 3 complete cycles to confirm menstrual relationship and predict timing 4, 8

First-Line Prophylactic Options

Long-acting triptans (preferred):

• Frovatriptan 2.5mg twice daily for 5 days starting 2 days before expected menstruation—has four randomized controlled trials demonstrating efficacy 1, 5
• Naratriptan 1mg twice daily using same 5-day perimenstrual schedule—supported by two randomized trials 1, 5
• Zolmitriptan 2.5mg three times daily is an alternative with one positive trial 5

NSAIDs:

• Naproxen sodium 500-550mg twice daily for 5 days starting 2 days before menses shows statistically significant benefit 1, 5

Alternative Hormonal Approach

• Transcutaneous estradiol 1.5mg daily (gel or patch) applied perimenstrually has grade B evidence for pure menstrual migraine 1, 2
• Contraindicated in women with migraine with aura due to increased stroke risk 1
• Continuous combined hormonal contraceptives can benefit women with pure menstrual migraine without aura only 1

Daily Preventive Therapy

When to Use

• Reserve for women with frequent migraines throughout the entire month, not just perimenstrually 1, 2

Standard Options

• Beta-blockers (propranolol 120-240mg daily), candesartan, topiramate, or amitriptyline 1, 9

Critical Drug Interaction Warning

• Many antiepileptic preventives (topiramate, lamotrigine) reduce oral contraceptive efficacy through enzyme induction 5
• Topiramate has least effect on oral contraceptives at doses below 200mg/day 5

Adjunct Medications

• Prokinetic antiemetics (metoclopramide, domperidone) for associated nausea/vomiting 1

Medications to Avoid

• Never use opioids or barbiturates—poor efficacy, dependency risk, and rebound headaches 1, 2
• Oral ergot alkaloids have poor efficacy and potential toxicity 1

Special Population Considerations

Pregnancy

• Paracetamol is first-line despite relatively poor efficacy 3, 2
• NSAIDs permitted only during second trimester 2

Breastfeeding

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

Monitoring and Follow-Up

• Evaluate treatment response within 2-3 months after initiation or change 1
• Use headache calendars to track attack frequency, severity, and medication use 3, 1
• Limit triptan use to prevent medication overuse headache—educate patients on rebound risk 1

Common Pitfalls to Avoid

• Failing to prospectively document the menstrual relationship with headache diaries before diagnosing menstrual migraine 7, 4
• Using short-acting triptans for prophylaxis instead of long-acting formulations (frovatriptan, naratriptan) 5
• Prescribing hormonal contraceptives to women with migraine with aura 1
• Delaying triptan administration until headache is severe rather than taking early when mild 1, 4