What is the best treatment approach for a young to middle-aged female patient with a history of migraine with aura who is experiencing dysmenorrhea?

Management of Dysmenorrhea in a Patient with Migraine with Aura

Combined hormonal contraceptives are absolutely contraindicated in women with migraine with aura due to increased stroke risk, so NSAIDs become the cornerstone treatment for both dysmenorrhea and any menstrual-related migraine attacks. 1, 2

Critical Contraindication

• Women with migraine with aura must never receive combined hormonal contraceptives, regardless of menstrual cycle association, due to significantly elevated ischemic stroke risk 1, 2, 3
• This contraindication applies even if the patient has pure menstrual symptoms, as the presence of aura at any time makes estrogen-containing contraceptives unacceptable 1, 3

First-Line Treatment for Dysmenorrhea

NSAIDs serve dual purpose in this population—treating both dysmenorrhea and migraine attacks:

• Ibuprofen 400-800 mg every 4-6 hours is FDA-approved for dysmenorrhea and effective for mild-to-moderate migraine 4, 5
• Naproxen sodium 275-550 mg every 2-6 hours provides longer duration of action and can be used perimenstrually 4
• Start NSAIDs at the earliest onset of menstrual symptoms or pain to maximize effectiveness 4
• NSAIDs address the shared prostaglandin-mediated pathway underlying both dysmenorrhea and menstrual migraine 3, 6

Escalation Strategy for Breakthrough Migraine

If NSAIDs alone provide inadequate relief for migraine attacks:

• Add a triptan to the NSAID regimen for moderate-to-severe migraine attacks 1, 4
• Sumatriptan 50-100 mg plus naproxen sodium (available as combination tablet) is particularly effective for menstrual migraine with concurrent dysmenorrhea 7, 8
• Never administer triptans during the aura phase—they are ineffective and should only be used when headache begins 2, 4
• Alternative triptans include rizatriptan 10 mg or other agents if sumatriptan is not tolerated 4

Perimenstrual Prophylaxis Option

For predictable menstrual migraine attacks despite acute treatment:

• Frovatriptan 2.5 mg twice daily starting 2 days before expected menstruation and continuing for 5-6 days 4
• Naratriptan 1 mg twice daily using the same timing is an alternative 4
• Long-acting NSAIDs (naproxen) can also be used perimenstrually for 5 days beginning 2 days before menstruation 1, 4
• This approach requires predictable menstrual cycles 6

Daily Migraine Prevention (If Needed)

If migraines occur frequently throughout the month, not just menstrually:

• First-line: Propranolol 80-160 mg daily (long-acting formulation) or metoprolol 50-100 mg twice daily 1, 2, 4
• Alternative first-line: Topiramate 50-100 mg daily (contraindicated in pregnancy, nephrolithiasis, glaucoma) 1, 2, 4
• Second-line: Amitriptyline 10-100 mg at night 1, 4
• Evaluate treatment response within 2-3 months after initiation 1, 2, 4

Progestin-Only Contraceptive Options

If contraception is needed:

• Progestin-only methods are safe in women with migraine with aura (pills, implants, IUDs, injections) 2
• These do not carry the stroke risk associated with estrogen-containing contraceptives 2

Monitoring and Pitfalls

• Use headache calendars to track attack frequency, severity, and medication use 1, 4
• Avoid medication overuse: limit triptan use to prevent rebound headaches and medication overuse headache 4, 9
• Avoid opioids and barbiturates due to dependency risk, rebound headaches, and poor efficacy 4
• Key outcome measures include attack frequency (migraine days per month), pain intensity, and functional disability 1, 2