What are the treatment options for migraine headaches that occur before the menstrual period (menstruation)?

From the Guidelines

For treating migraines that occur before menstrual periods, I recommend initiating perimenstrual preventive treatment with a long-acting NSAID, such as naproxen, or a triptan, such as frovatriptan or naratriptan, for 5 days, starting 2 days before the expected first day of menstruation. This approach is supported by the most recent evidence from the study published in Nature Reviews Neurology in 2021 1. The study suggests that initiation of perimenstrual preventive treatment should be considered, and this approach typically involves daily intake of a long-acting NSAID or triptan for 5 days, beginning 2 days before the expected first day of menstruation.

Some key points to consider when treating migraines before menstrual periods include:

• The use of combined hormonal contraceptives, which may be beneficial for women with pure menstrual migraine without aura, but are contraindicated in women with migraine with aura due to an increased risk of stroke 1.
• The importance of tracking migraine patterns with a headache diary to determine the best timing for preventive treatment.
• Lifestyle modifications, such as stress management, regular sleep, and avoiding other triggers during the vulnerable period, can enhance medication effectiveness.

It's also important to note that the treatment of migraines before menstrual periods should be individualized, taking into account the patient's medical history, lifestyle, and preferences. As stated in the study published in Nature Reviews Neurology in 2021, consideration should be given to preventive treatment in patients who are adversely affected by migraine on ≥2 days per month despite optimized acute treatment 2. However, the most recent and highest quality study 1 provides the most relevant guidance for treating migraines that occur before menstrual periods.

From the FDA Drug Label

The efficacy of sumatriptan tablets was unaffected by ... relationship to menses; The recommended dose of sumatriptan tablets is 25 mg, 50 mg, or 100 mg.

• Migraine treatment before menstrual period:
  • The efficacy of sumatriptan is unaffected by the relationship to menses.
  • Dosing: 25 mg, 50 mg, or 100 mg can be used.
  • A second dose may be administered at least 2 hours after the first dose if the migraine has not resolved or returns after a transient improvement [3] [4].

From the Research

Treatment Options for Migraine Before Menstrual Period

• Acute treatment: Triptans, such as sumatriptan, rizatriptan, and frovatriptan, are recommended as first-line treatments for moderate to severe migraine attacks, including menstrual migraine 5, 6, 7.
• Short-term preventive therapy: Frovatriptan has been shown to be effective in the short-term preventive therapy of menstrual migraine, with a grade A recommendation from guidelines 5, 8, 7.
• Daily preventive treatment: Estrogen-containing contraceptive treatment may be effective in appropriately selected patients, but caution is indicated when using anti-epileptic medications that can affect the efficacy of oral contraceptives 8, 6, 9.
• Hormone therapies: The withdrawal of estrogen has been correlated with the onset of menstrual migraine, providing an opportunity for specific treatment with hormone therapies, 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 9.

Medications Used for Treatment

• Frovatriptan: Has been shown to be effective in treating the acute attack and in short-term preventive therapy of menstrual migraine, with a lower risk of treatment-emergent adverse events 5, 8, 7.
• Rizatriptan: Has the best overall evidence for acute treatment of menstrual migraine, with pain-free responses of 33-73% at 2 hours 6.
• Sumatriptan: Has been shown to be effective in acute treatment of menstrual migraine, with an efficacy of 61-63% in terms of 2 hour pain freedom 6, 7.
• Naratriptan: Has been shown to be effective in short-term prevention of menstrual migraine, with statistically significant results 6, 7.

Important Considerations

• Menstrual migraine can be very difficult to treat, and treatment strategies should be individualized based on the patient's pattern of migraine and occurrence of migraine outside the menstrual period 8, 6, 9.
• Caution is indicated when using anti-epileptic medications that can affect the efficacy of oral contraceptives, and topiramate has the least effect on oral contraceptives at doses below 200 mg/day 6.