What is the appropriate evaluation and management for a reproductive‑age woman with sporadic menstrual‑related migraines accompanied by nausea and ocular pain, who has never been diagnosed or treated?

Evaluation and Management of Menstrual-Related Migraine

For a reproductive-age woman with sporadic menstrual-related migraines, initiate acute treatment with NSAIDs (ibuprofen or naproxen 500 mg) or triptans (sumatriptan 50-100 mg or rizatriptan 10 mg) at headache onset, and consider perimenstrual short-term prophylaxis with frovatriptan 2.5 mg twice daily or naratriptan 1 mg twice daily starting 2 days before expected menstruation for 5-6 days if attacks are predictable and disabling. 1, 2

Initial Diagnostic Evaluation

Confirm the Diagnosis

• Apply ICHD-3 diagnostic criteria through detailed headache history, documenting the temporal relationship between migraine attacks and menstrual cycle 1
• Use the three-item ID-Migraine questionnaire or five-item Migraine Screen Questionnaire as validated screening tools 1
• Have the patient maintain a headache diary for at least 3 consecutive menstrual cycles to establish the pattern (attacks occurring from day -2 to day +3 of menstruation, where day 1 = first day of bleeding) 3, 4, 5

Rule Out Secondary Causes

• Neuroimaging is not indicated unless red flags suggest a secondary headache disorder (new onset headache with atypical features, neurological deficits, or sudden severe headache) 1
• The associated nausea and eye pain described are typical migraine features and do not necessitate imaging in isolation 1

Acute Treatment Strategy

First-Line Acute Medications

• NSAIDs: Naproxen 500 mg or ibuprofen 400-800 mg at headache onset 1
• Triptans: Rizatriptan 10 mg has the best overall evidence for menstrual migraine with 2-hour pain freedom rates of 33-73% and sustained pain relief of 63% between 2-24 hours 3
• Sumatriptan 50-100 mg is equally effective with 61-63% pain freedom at 2 hours 3, 4
• Combination sumatriptan 85 mg/naproxen 500 mg offers synergistic benefit 4

Antiemetic Adjunct

• Add metoclopramide 10 mg orally for nausea, which also has direct antimigraine effects 6
• Prochlorperazine 25 mg (oral or suppository) can relieve both nausea and headache pain 6

Critical Medication Limits

• Limit triptan use to <10 days per month to prevent medication overuse headache 1, 7
• Limit NSAID use to <15 days per month for the same reason 1, 6

Perimenstrual Short-Term Prophylaxis

When to Consider

Initiate short-term prophylaxis if the patient experiences:

• Two or more disabling attacks per month for 3+ consecutive months 1, 2
• Predictable menstrual timing that allows scheduled prevention 1, 4
• Inadequate response to acute treatment alone 1
• Menstrual attacks that are more severe, longer-lasting, or more resistant to acute treatment 3, 4

Evidence-Based Regimens

Triptan-based prophylaxis (strongest evidence):

• Frovatriptan 2.5 mg twice daily starting 2 days before expected menstruation for 6 days reduces menstrual migraine occurrence from 67% to 38% (P<0.001) 1, 2, 8
• Naratriptan 1 mg twice daily for the same perimenstrual window 1, 2, 4
• Zolmitriptan 2.5 mg three times daily is an alternative 3

NSAID-based prophylaxis:

• Naproxen 500 mg twice daily starting 2 days before menstruation for 5-7 days 1, 3, 4
• Can be combined with triptan prophylaxis for enhanced effect 2

Dosing Schedule

• Begin treatment 2 days before the expected first day of menstruation 1, 2, 4
• Continue for 5-6 days total (through day +3 of bleeding) 1, 2, 8
• This targets the high-risk window when estrogen withdrawal triggers attacks 9, 5

Patient Education and Lifestyle Modifications

Essential Counseling Points

• Explain that menstrual migraine results from estrogen withdrawal, not cure but control is the realistic goal 1, 5
• Emphasize that effective treatment reduces attack frequency, duration, and disability to allow normal functioning 1
• Discuss the importance of avoiding medication overuse, which can paradoxically worsen headaches 1, 7

Lifestyle Interventions

• Maintain adequate hydration and regular meal timing to avoid hypoglycemia triggers 1, 6
• Ensure consistent, sufficient sleep patterns (irregular sleep is a predisposing factor) 1, 6
• Regular physical activity improves overall migraine control 1, 6
• Identify and avoid self-evident trigger factors, though menstruation itself is often the primary trigger 1

Special Contraceptive Considerations

Hormonal Contraception

• Continuous combined hormonal contraceptives (without hormone-free intervals) may benefit women with pure menstrual migraine without aura by eliminating estrogen withdrawal 1
• Absolute contraindication: Combined hormonal contraceptives are contraindicated if the patient develops migraine with aura due to increased stroke risk 1, 2
• This patient should be specifically questioned about aura symptoms (visual disturbances, sensory changes, speech difficulties lasting 5-60 minutes before headache) 1

When to Escalate to Daily Prevention

Consider daily preventive therapy if:

• Perimenstrual prophylaxis fails to provide adequate control 1, 2
• Attacks occur frequently outside the menstrual window (>2 attacks/month causing 3+ days of disability) 1
• The patient uses acute medication more than twice weekly 2

Daily Preventive Options

• First-line: Propranolol 80-160 mg daily (long-acting formulation) 1, 2
• Second-line: Topiramate 50-100 mg daily reduces menstrual migraine frequency by 46%, but requires effective contraception due to teratogenicity 1, 2
• Third-line: OnabotulinumtoxinA 155-195 units every 12 weeks for chronic migraine (≥15 headache days/month) 1, 2
• Newer agents: CGRP monoclonal antibodies (erenumab 70-140 mg monthly, fremanezumab 225 mg monthly) for refractory cases 2

Critical Contraindications and Safety

Absolute Contraindications to Triptans

• Known coronary artery disease or Prinzmetal's angina 7
• History of stroke or transient ischemic attack 7
• Uncontrolled hypertension 7
• Wolff-Parkinson-White syndrome or other cardiac accessory pathway disorders 7

Cardiovascular Risk Assessment

• For triptan-naive patients with multiple cardiovascular risk factors (age >40, diabetes, hypertension, smoking, obesity, strong family history of CAD), perform cardiovascular evaluation before prescribing 7
• Consider administering first triptan dose in a supervised setting with post-dose ECG for high-risk patients 7

Pregnancy Planning

• Sodium valproate is absolutely contraindicated in women of childbearing potential due to high teratogenic risk 1, 6, 2
• Topiramate requires effective contraception due to fetal anomalies 6, 2
• If pregnancy is planned or occurs, switch to acetaminophen 1000 mg as first-line acute treatment 6

Follow-Up and Monitoring

Evaluation Timeline

• Reassess treatment response at 2-3 months after initiating or changing therapy 1, 2
• Use headache calendars to objectively track attack frequency, severity, and disability 1, 2
• Apply the Migraine Treatment Optimization Questionnaire (mTOQ-4) to evaluate acute medication effectiveness 1

Treatment Failure Assessment

Before concluding treatment has failed, verify:

• Adequate dosing and correct medication timing 1
• Medication adherence (non-adherence is a common cause of apparent failure) 1
• Absence of medication overuse headache 1, 7

Common Pitfalls to Avoid

• Do not delay acute treatment—early intervention is more effective than waiting for severe pain 1
• Do not prescribe opioids or butalbital-containing medications, which cause dependency and medication overuse headache 6
• Do not use combined hormonal contraceptives if aura develops, as stroke risk increases significantly 1, 2
• Do not continue ineffective preventive therapy beyond 2-3 months without reassessment and adjustment 1