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Menstrual Migraine

Menstrual migraine is more than "just a hormone headache". For many years when I ask a patient if they have headaches, they often say "No, just my normal monthly headache."

Well that's another "myth about headaches"! Headaches are not normal no matter when they occur. Even if you have been told in the past that "there is no such thing as a menstrual migraine" or "everyone gets headaches like that", this is not true.

These types of migraines are real. Period. (No pun intended!)

What is the definition of a true menstrual migraine? One that occurs 2 days before, during, or up to 3 days after your cycle. At the present time, researchers have located 5 receptor sites in the brain that are estrogenic so to speak. There are some in the limbic system deep in the brain which regulates mood. There are also receptors on the pial blood vessels that are outside the meninges. It is these vessels that finally dilate during a migraine and cause the pounding pain. Serotonin also plays a role as it has been found to interact with women's hormones.

Hormone related migraine may occur outside those times but close to them or at midcycle. The word hormone literally means to set in motion, which describes the cycling mechanism within the body. It applies to any hormonal system including those found in men, but the cycling may be small in nature.

OK..so now what? You are a woman stuck with cycles for many years until you get to menopause and even then you might have migraines with menopause.

menstrual migraine


There are several ways to "manipulate" things so to speak, during this time of the month. The table below lists some options that include both hormonal and non-hormonal considerations during the week of your cycle.

menstrual migraine

Many women have gone on the newer 90-day birth control pills and thereby avoid a mentrual migraine for several months. Then when one does strike, it is more easily treated with different options.

At times, depending on the severity of the headache, I will give a woman a higher dose of magnesium and or a steroid pak (medrol dose pak) for one week.

We may also add in longer acting triptans such as Frova taken twice a day at the onset of menses for two days. This front loads you with a drug that will last for a few days and prevent the recurring headache that happens with a shorter acting triptan such as Imitrex. For more severe disabling headache, consider an injectable such as Imitrex or Sumavel. DHE-45 which is in the ergot class is excellent for menstrual migraine because unlike the triptans which affect only the arteries, DHE treats both arterial and venous dilation. This is why these types of headaches can be so difficult to manage. There are a variety of mechanisms going on within the brain leading up to the end result of severe head pain.

Both the triptans and DHE can be combined with naprosyn or naproxyn to take at the onset of the headache. This results in a strong response to abort pain. The nice thing about this is you can utilize this method every month without worrying about taking medications that are addictive.

Below is a table of treatments that your provider could consider for you. This includes acute treatment at the onset of the migraine and preventative methods.

Non-HormonalHormonal
NSAIDSEstrogen gels
TriptansEstrogen patches
ErgotsOral estrogen pills
MagnesiumDonnagel
Incr Anti-seizuresDepro-Provera

Another interesting concept that I have been utilizing is increasing your daily medication for one week. For instance, if you are taking Topamax or Depakote, increase the dose slightly. This will help blunt or even prevent the menstrual migraine during that week. Then, after the week is over you will go back down to the former dose of the drug. You can also increase your magnesium during this week and go from 400mg to 600mg and again, reduce it when the week is over.

References:

Brandes JL. The influence of estrogen on migraine: a systematic review. JAMA. 2006;295:1824–1830.

Headache (Headache Classification Committee of the International Headache Society). The International Classification of Headache Disorders. 2nd edition. Cephalalgia. 2004:24(suppl 1):9–160.

Tepper SJ, Rapoport AM, Sheftell FD.Mechanisms of action of the 5- HT1B/1D receptor agonists. Arch Neurol. 2002;59:1084–1088.

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