From the Guidelines
Preventing menstrual migraines requires a multi-faceted approach, including hormonal and non-hormonal strategies, with the most effective strategy being the initiation of perimenstrual preventive treatment, such as daily intake of a long-acting NSAID or triptan for 5 days, beginning 2 days before the expected first day of menstruation, as recommended by the 2021 study in Nature Reviews Neurology 1.
Key Considerations
- For women with predictable menstrual cycles, starting preventive medication 2-3 days before expected menstruation and continuing through the first few days of bleeding is recommended.
- Nonsteroidal anti-inflammatory drugs (NSAIDs) like naproxen sodium (500mg twice daily) or ibuprofen (400-600mg three times daily) can be effective when started before pain begins.
- Triptans such as frovatriptan (2.5mg once or twice daily), naratriptan (1-2.5mg twice daily), or zolmitriptan (2.5mg twice daily) can be used as mini-prophylaxis for 5-7 days surrounding menstruation.
Hormonal Options
- Continuous or extended-cycle combined hormonal contraceptives can prevent estrogen withdrawal, but are contraindicated in women with migraine with aura, as noted in the 2021 study in Nature Reviews Neurology 1.
- Estrogen supplements (estradiol gel 1.5mg or patch 100μg) can be used during the late luteal phase and menstruation.
Lifestyle Modifications
- Maintaining regular sleep patterns, staying hydrated, managing stress, and avoiding known triggers like alcohol or certain foods during the vulnerable period are important.
- Magnesium supplementation (400-600mg daily) may help reduce frequency and severity of menstrual migraines by improving neurotransmitter function and vascular tone, although the most recent and highest quality study, the 2025 study in Annals of Internal Medicine 1, does not specifically address magnesium supplementation for menstrual migraines.
Treatment Approach
- The 2025 study in Annals of Internal Medicine 1 recommends initiating pharmacologic treatment for the prevention of migraine at a low dose and gradually increasing the dose until desired outcomes are achieved, and switching pharmacologic treatment if an adequate response is not achieved during a reasonable trial period.
- The use of a headache diary may help to determine treatment efficacy, identify analgesic overuse, and follow up on migraine progression, as suggested by the 2025 study in Annals of Internal Medicine 1.
From the FDA Drug Label
Migraine: In a 34-week, placebo-controlled, 4-period, dose-finding crossover study with a double-blind randomized treatment sequence, 62 patients with migraine received propranolol 20 to 80 mg 3 or 4 times daily The headache unit index, a composite of the number of days with headache and the associated severity of the headache, was significantly reduced for patients receiving propranolol as compared to those on placebo
The text does not specifically mention menstrual migraine, only migraine in general. Therefore, no conclusion can be drawn about the prevention of menstrual migraine. 2
From the Research
Prevention of Menstrual Migraine
Prevention of menstrual migraine can be achieved through various methods, including:
- Short-term perimenstrual prevention employing nonsteroidal anti-inflammatory medications, triptans, or hormone-containing preparations 3
- Continuous prevention using hormonal therapies or standard anti-migraine prophylaxis 3
- Stepped-up acute treatment, mini-prevention with NSAIDs, magnesium, triptans or estrogen, or daily prevention with continuous contraception 4
- Prophylactic strategies can reduce the frequency and severity of attacks and acute treatment is more effective 5
- Contraceptive strategies offer the opportunity for treating menstrual migraine in women who also require effective contraception 5
Treatment Options
Treatment options for menstrual migraine include:
- Acute treatment with triptans, such as sumatriptan, rizatriptan, naratriptan, zolmitriptan, and almotriptan 6
- Short-term prophylaxis with frovatriptan, zolmitriptan, or naratriptan, as well as magnesium, estrogen, naproxen sodium, or dihydroergotamine 6
- Daily prevention with anti-epileptic medications, such as topiramate, which has the least effect on oral contraceptives at doses below 200 mg/day 6
- Hormone treatment, such as continuous combined hormonal contraceptives (CHCs) with no placebo pills or using just two days of placebo pills to avoid the estrogen withdrawal trigger 7
Important Considerations
Important considerations when treating menstrual migraine include:
- The withdrawal of estrogen has been correlated with the onset of menstrual migraine, providing an opportunity for specific treatment with hormone therapies 7
- Menstrual migraine with aura is uncommon, and the use of combined hormonal contraceptives is not recommended due to the increased risk of stroke 7
- Anti-epileptic medications used in migraine prevention can affect the efficacy of oral contraceptives and hormonal treatments, so caution is indicated when these are used 6