What are the likely causes and appropriate acute and preventive treatments for occipital headaches that occur with menses in a reproductive‑age woman?

Occipital Headaches During Menstruation

Most Likely Diagnosis

Occipital headaches occurring with menses in a reproductive-age woman are most likely menstrually-related migraines, which affect approximately 50% of women with migraine and are triggered by estrogen withdrawal just before menstruation begins. 1, 2

• Menstrual migraines typically occur on or between 2 days before menstruation and the first 3 days of bleeding, with estrogen withdrawal leading to loss of serotonergic tone as the primary trigger 3, 2
• These attacks are characteristically more severe, longer-lasting, and more resistant to treatment compared to migraines at other times of the cycle 3, 4, 2
• Any woman of reproductive age presenting with migraine should be asked about the relationship between her attacks and menstruation 1

Acute Treatment Algorithm

Start with NSAIDs as first-line acute treatment, then escalate to triptans if NSAIDs provide inadequate relief. 1

First-Line: NSAIDs

• Ibuprofen, diclofenac potassium, or acetylsalicylic acid have the strongest evidence for acute menstrual migraine 1
• Naproxen sodium 500 mg shows modest but statistically significant effects 1, 3
• Limit NSAID use to <15 days per month to prevent medication overuse headache 5

Second-Line: Triptans

• Triptans must be taken early when headache is still mild for maximum effectiveness 1
• Rizatriptan 10 mg has the best overall evidence, with 2-hour pain freedom rates of 33-73% and sustained pain relief of 63% between 2-24 hours 4
• Sumatriptan 50-100 mg and combination sumatriptan/naproxen 85 mg/500 mg have proven efficacy 3
• Limit triptan use to <10 days per month to prevent medication overuse headache 5

Preventive Treatment Strategy

If optimized acute treatment fails, initiate perimenstrual prophylaxis starting 2 days before expected menstruation for 5 days total. 1

Short-Term Perimenstrual Prophylaxis (First-Line)

• Frovatriptan 2.5 mg twice daily has grade B evidence and the best overall evidence among triptans for short-term prevention 3, 4
• Naratriptan 1 mg twice daily is an alternative with proven efficacy 3, 4
• Naproxen sodium taken perimenstrually shows statistically significant benefit 4

Hormonal Approach (Alternative)

• Transcutaneous estradiol 1.5 mg has grade B evidence for perimenstrual prophylaxis 1, 3
• Important caveat: hormonal approaches only benefit patients whose migraines are menstruation-related; they do not help migraines occurring at other times 1

Long-Term Daily Prevention (If Perimenstrual Prophylaxis Fails)

For women requiring continuous prevention, follow the 2025 American College of Physicians stepwise approach: 6

1. First-line options: β-blockers (metoprolol or propranolol), valproate, venlafaxine, or amitriptyline 6
2. Second-line: CGRP antagonist-gepants or CGRP-mAbs if first-line agents fail or are not tolerated 6
3. Third-line: Topiramate only after trials of first-line agents and CGRP medications have failed 6

• Propranolol 80-160 mg daily in long-acting formulations is particularly appropriate for breastfeeding women due to minimal breast milk transfer 5
• Critical pitfall: Many antiepileptic medications (valproate, topiramate) can reduce oral contraceptive efficacy through enzyme induction; topiramate has the least effect at doses below 200 mg/day 4

Special Population Considerations

Pregnancy

• Paracetamol 1000 mg is first-line despite relatively poor efficacy 1
• NSAIDs can only be used during the second trimester 1

Breastfeeding

• Paracetamol 1000 mg remains first-line, with ibuprofen and sumatriptan considered safe 5, 1
• Propranolol is the preferred preventive agent with minimal breast milk transfer 5
• Avoid CGRP inhibitors during breastfeeding due to insufficient safety data 5

Key Clinical Pitfalls to Avoid

• Do not delay triptan administration—they must be taken when headache is still mild for optimal efficacy 1
• Monitor for medication overuse headache—this is more likely with menstrual migraines due to their severity and treatment resistance 5, 2
• Do not use opioids or butalbital-containing medications—these cause dependency and rebound headaches 5
• Assess adherence expectations—improvement with preventive medications occurs gradually over weeks, not immediately 6
• Consider cost in treatment selection—CGRP medications are substantially more expensive than traditional preventive agents, and oral medications are generally preferred over injectables by patients 6