Breaking down three main treatment strategies for menstrual migraine and how to pick the best option for you
For nearly two out of three women with migraine, attacks occur around the same time as their period. By definition, if you have migraine attacks that start between the two days before your period and the third day of flow, you likely have menstrual migraine. These attacks are often more severe, longer, and cause greater light sensitivity than attacks occurring other times of the month.
Menstrual migraine is caused by the rapid drop in estrogen levels that occurs just prior to your period. “I have patients that tell me, ‘Aren’t headaches a part of having a menstrual cycle?’” says Dr. Paru David, an internist who works in the division of women’s health internal medicine at Mayo Clinic in Arizona. “I educate them that not all women have headaches during their menstrual cycles.”
Migraine attacks occurring just before and during a woman’s period can be the most challenging kind to treat. They do not always respond to the same medicines that work on migraine attacks happening at other times. The reason medications don’t work the same is not entirely clear. But it’s likely related to estrogen’s effects on other chemicals.
Dr. David has words of encouragement for women experiencing menstrual migraine: “The number one thing is that you don’t need to suffer. We have some treatment options available to help your migraine attacks.” There are three general treatment strategies: acute treatment designed to hit these migraine attacks effectively; mini-preventive treatment given before and during a womans’ period; and continuous preventive treatment used daily throughout the month.
There are several different kinds of acute treatments that are effective in treating menstrual migraine.
A fast-acting triptan (such as sumatriptan, rizatriptan, zolmitriptan, almotriptan, or eletriptan) taken early in the migraine attack in combination with a non-steroidal anti-inflammatory drug (NSAID) such as naproxen or ibuprofen, may be sufficient for managing symptoms.
In the middle of a migraine attack, pills can be slow to work because they need to be digested and absorbed. But injections bypass the digestive tract and can work faster. Sumatriptan is the only injectable triptan and it comes in both needle and needle-free auto injecting syringes. It is very fast, often giving relief in less than 10 minutes. Plus it can be used effectively even if you are vomiting or extremely nauseous.
Dihydroergotamine (DHE) is also an injectable medication that can be used, but it is not available with an auto-injector, which means you’ll have to prepare the syringes yourself.
Patients can combine an injectable sumatriptan or DHE with an NSAID for an even greater benefit.
A nasal triptan such as zolmitriptan or sumatriptan is faster than a pill. It also avoids the problem of vomiting and losing a pill. They do not work quite as fast an injection but for some are more comfortable than an injection. DHE is also available as a nasal spray.
Some women find adopting a mini-preventive treatment approach helpful for menstrual migraine prevention. While there are studies looking at these strategies, they do not have FDA approval. In mini-prevention, a woman takes a daily medication prior to the onset of the menstrually related attacks. They usually take these medications for 5 to 7 days in a row.
Non-Steroidal Anti-Inflammatories (NSAIDs)
NSAIDs taken twice a day during the 5-7 days around the start of a period may decrease or prevent the menstrual migraine. If the migraine attack still occurs during this time, it is typically less severe and becomes more responsive to treatment by a triptan. Naproxen 550 milligrams dosed twice a day as mini-prevention was shown to be effective when studied. Other NSAIDs like ibuprofen are likely to give similar results.
Patients can use estrogen supplementation with a pill, vaginal gel or patch during the menstrual week to prevent the natural estrogen drop that triggers the menstrual migraine. This approach is easier in those with predictable menstrual cycles. Often, this is most convenient if you are already taking a pill or using a vaginal ring for birth control.
Multiple studies have looked at triptans—the acute medications typically used to treat regular migraine attacks—dosed twice a day throughout a woman’s period. This approach appears to decrease or prevent menstrual migraine. Women with menstrual migraine and frequent migraine attacks throughout the rest of the month should be cautious about their triptan use in order to avoid medication overuse.
Triptan dosing for mini-prevention is generally twice daily for four to five days in the menstrual window. In this situation, doctors recommend long-lasting triptans such as naratriptan and frovatriptan.
Magnesium started on day 15 of the menstrual cycle, or 15 days from the start of your period, and continued until the next period begins is another mini-prevention strategy that was found effective in a controlled trial. Because the timing relies on your previous period, it’s not necessary to have regular cycles to time this prevention, which makes it a versatile and safe intervention for women without regular cycles.
Continuous Preventive Treatment
In women with irregular periods or those for whom mini-prevention does not work, treatment strategies used throughout the month may be the best option.
Dosing birth control pills continuously so that there is no break for a monthly period can be an effective way to reduce menstrual migraine. “Most people know birth control pills as 21 seven-day formulations—where a woman takes a pill for 21 days, followed by seven days of placebo, which is when she would have her menstrual cycle,” explains Dr. David. “It is that drop in hormones that precipitates a migraine headache. So if we eliminate that placebo week and have [patients] take hormones continually through that, in an extended cycle, it helps eliminate those migraine headaches.”
You can also use hormonal approach with the vaginal ring so that at the time you remove the ring, you insert a new one immediately instead of waiting for the end of the menstrual period. Typically, a break is given for a menstrual period every 3-6 months, at which time your doctor may implement aggressive treatment of the menstrual migraine or recommend using a mini-prevention strategy.
In patients using other forms of hormonal contraception with estrogen, it may be beneficial to use the lowest possible dose of estrogen. This will minimize the drop in estrogen in the pill-free week.
Which Treatment Option Is Best for You?
Keeping a diary of your headaches, including when they occur in relation to your menstrual cycle, as well as their severity and response to treatment, will help your doctor determine the presence of menstrual migraine. “There are not any blood tests or any type of imaging that can be done to diagnose this,” says Dr. David. “It’s purely done based on the history.”
A headache and menstrual diary can also help you and your doctor identify the best treatment for you. Women with menstrual migraine who have painful cramps may benefit more from a NSAID strategy with a triptan for rescue. Those who have predictable cycles and migraine attacks may benefit from a mini-prevention strategy. Those who don’t have regular cycles can try other options.
It is also important to discuss with your doctor any personal risk factors you may have for taking oral contraception, such as an increased risk of stroke, heart disease or blood clots, as hormonal birth control can affect women with migraine differently. Please let your provider know if you have migraine with aura when discussing hormonal options.
Based on all of this information, your doctor may recommend a specific acute treatment; mini-prevention with NSAIDs, magnesium, triptans or estrogen; or daily prevention with continuous birth control. In general, most providers recommend trying medical strategies before hormonal ones as hormones may carry extra risks. Ultimately, your best treatment option will depend on your overall health and response to treatment.
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Reviewed for accuracy by the American Migraine Foundation’s subject matter experts, headache specialists and medical advisers with deep knowledge and training in headache medicine. Click here to read about our editorial board members.