Have you noticed a link between your monthly period and your migraine attacks? Understanding your patterns, triggers, and diagnosis can help you prevent menstrual migraine attacks.
What Is Menstrual Migraine?
Broadly speaking, menstrual migraine is a migraine attack (or multiple attacks) that occurs around the time of your menstrual periods. The definition is a bit confusing because many women have exacerbations of migraine around the time of their menstrual cycle, but then they also have attacks outside of their menstrual period. The question is whether to call that exacerbation “menstrual migraine.” Often migraine attacks around menstruation are more severe and debilitating than headaches that may occur at other times of the month.
Pure menstrual migraine is migraine disease that only reveals itself during the time of the month around a woman’s menstrual cycle. However, it is fairly unusual that women with menstrual migraine don’t also have migraine attacks at some other points during the month.
Do I Need a Doctor to Diagnose Menstrual Migraine?
A person already diagnosed with migraine can likely figure out that they have menstrual migraine, but it’s important to discuss it with a healthcare provider to confirm it. It is also useful to think about specific strategies for preventive treatment that may be geared particularly toward this type of disease after menstrual migraine is diagnosed.
What Are the Signs and Symptoms of Menstrual Migraine?
Menstrual migraine symptoms are generally the same as migraine symptoms— head pain (one-sided, moderate to severe, throbbing pain); sensory sensitivities (to light, sound, smell, and/or touch); nausea; and vomiting — with a couple of interesting differences.
There’s some consensus that a migraine attack that occurs around the time of the menstrual period is more severe and potentially harder to manage with acute treatment. Although the evidence for that is not necessarily compelling, the general sense of many practitioners is that those migraine attacks occurring with the menstrual period may have greater pain intensity and be more challenging to manage acutely.
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What Causes Menstrual Migraine?
That’s a huge, open-ended, and interesting question. What is it about the menstrual period or hormonal changes that is, essentially, a trigger for migraine attacks? A long-standing hypothesis is that it’s due to falling levels of estrogen. Levels of estrogen rise throughout the month and then, before the menstrual period, rapidly drop. That’s part of the hormonal cycle that’s underlying the menstrual period. There have been a number of studies showing that the triggering of a migraine attack is related to that drop in estrogen levels. This estrogen-associated migraine theory remains the prevailing view regarding what is involved in menstrual migraine, or “hormone headaches.”
It’s important to understand, though, that it may be much more complicated than that because estrogen isn’t the only thing that’s changing around the hormonal cycle. The menstrual cycle is driven by higher brain centers in the hypothalamus, which is the part of the brain that’s the ultimate clock for the reproductive cycle. It’s possible that the cycling activity of the hypothalamus could be playing an important role, in addition to estrogen fluctuation.
Other changes are occurring in the body as well; these include changes in fluid balance and other factors that may not be directly related to estrogen. So it’s conceivable that there are factors other than estrogen levels involved.
How Long Can Complex Menstrual Migraine Attacks Last?
Given that menstrual-related migraine typically doesn’t include aura, what some people may call “complex migraine” is less likely to occur around the time of the menstrual period. Complex migraine is not a term used by most headache specialists. Sometimes it is used by non-specialists to refer to a migraine attack when symptoms other than headache are involved.
Migraine attacks associated with the menstrual period have the same duration as migraine attacks occurring outside of the menstrual period — however, in some cases, menstrual migraine attacks may be more sustained, lasting two or three days, as compared to other attacks.
What Treatment Options Are Available for Menstrual Migraine?
Menstrual migraine treatment is essentially the same as what’s used for migraine treatment, with some potential differences. The approaches that are similar can include the use of acute medications, preventive medications, lifestyle modifications, nutritional supplements, alternative and complementary therapies, and neuromodulation devices.
Mini-Prevention: NSAIDs and Triptans
For women who consistently have headache pain around the time of the menstrual period, a healthcare provider may recommend short-term preventive therapy (mini-prevention) or mini-prophylaxis — where medications are given only on the days of the month around the menstrual period to try to prevent menstrual migraine from occurring.
Keeping a consistent headache log is very helpful to best time when to begin preventive therapy as it relates to the start of menstruation.
Treatments can include over-the-counter medications like nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or naproxen sodium, but also opens the door to exploration of migraine-specific and menstrual migraine-specific options that can be used with, or instead of, those drugstore medications.
Mini-Prevention: Birth Control Pills and Hormone Therapy
There are also other medications to consider, like hormone therapy, or what used to be referred to as hormone replacement therapy. For example, it’s conceivable that taking hormonal birth control therapy, like an estrogen supplement, around the time of the menstrual period can be helpful in adjusting hormone levels for those sensitive to fluctuations; it has been shown to be helpful acutely.
A headache specialist also may recommend using continuous estrogen-containing birth control, and so may explore therapies such as oral contraceptives, an estrogen patch, or other sources of exogenous estrogen. This allows you to sustain a level of estrogen and not have a menstrual period by manipulating the system with exogenous estrogen. Using hormonal contraception can be useful for some people.
Jelena Pavlović, MD, PhD, associate professor of neurology at Albert Einstein College of Medicine and winner of the American Headache Society’s 2021 Women’s Health Science award, addressed this topic for the Migraine World Summit. She noted that mini-prevention, or mini-prophylaxis, has the potential to cut the number of headache days in half in menstrual-related migraine for those with regular menstrual cycles. It is that regular cycle that allows for timing of the medications used before menstruation and the predictable attacks of menstrual-related migraine associated with it.
However, estrogen-containing oral contraceptives or birth control do have their own risks and may not be appropriate for all patients with migraine, especially in the setting of cardiovascular disease risk factors.
Mini-Prevention: Supplements
Another potential and natural way to treat menstrual-related migraine is with magnesium, most commonly dosed at 400 to 500 mg daily; there’s potential for magnesium to have a preventive effect when given continuously. But some people who experience migraine attacks prefer to simply take it around the time of the menstrual period to have a specific effect on menstrual migraine, rather than taking it continuously throughout the month.
Another nutraceutical to consider is vitamin E dosed at 400 IU daily.
If taken solely around the menstrual period, either magnesium or vitamin E can be timed to begin one week before and during menstruation (two weeks total), so long as the cycle is regular. Otherwise, daily dosing can be used if the cycle is irregular.
Talk to your healthcare provider about what is right for you with regard to preventive medications, acute therapies, and alternative treatments.
What Are Some Tips for Living With Menstrual Migraine?
Calhoun AH. Understanding Menstrual Migraine. Headache. 2018 Apr;58(4):626-630
It may be important and useful to have a heightened awareness and avoid some of those other potential triggers at that time. Keeping a headache diary, on paper or in an app, can be helpful in more clearly assessing the impact of migraine on your life and treating menstrual migraine by helping to determine what’s working for and against you in migraine prevention.
It is also important to understand that a person with menstrual-related migraine who is using just acute medications, and not preventive therapy, is at increased risk of attacks during their menstrual period. It is important to be attuned to the importance of treating early and aggressively. That requires being aware of their cycles in a way that can enable them to treat earlier during that time period based on the likelihood that a migraine attack will occur.
