Treating menstrual migraine

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NSAIDS typically used in menstrual migraine include fenoprofen (600mg twice a day) or naproxen (550mg one to two times a day). Mefanamic acid (500mg, 3-4 x/day) is recommended for women with dysmenorrhoea or amenorrhoea.

Studies with the following triptans suggest that they too are effective for acute migraine attacks with menstruation; particularly in patients with dysmenorrhoea, infrequent attacks, or unpredictable attacks:

• Sumatriptan 50 or 100mg (grade "B" evidence)
• Rizatriptan 10mg (grade "B" evidence)
• Zolmitriptan 2.5mg (grade "C" evidence)
• Naratriptan 2.5mg, (grade "I"insufficient evidence)

Preventive treatment

For women with more frequent headaches (once a week or more), acute treatment can lead to medication overuse headaches. For these women, preventive treatment with supplemental oestrogen or a triptan is advised, generally beginning 2-3 days before anticipated headache (or menses) and continued for 5-7 days.

There is grade "B" evidence to support using supplemental synthetic oestrogen treatment, consisting of estradiol gel (1.5mg daily from 2-3 days before expected menstruation for 7 days) or transdermal synthetic oestrogen (100µg from 2-3 days before expected menstruation up to 4th or 5th day of menstruation), or using the triptans, frovatriptan (2.5mg BID) or naratriptan (1mg. BID), perimenstrually.

Dr Loder notes that the preventive strategy itself is more important than the particular drug prescribed. What makes it effective is accurately anticipating the headache and heading it off with medication.

Individual drug selection should depend on what works for the patient or what contraindications she may have. For example, supplemental oestrogen is not recommended for women with oestrogen-dependent conditions, and triptans are not recommended for women with coronary disease.

Dr Loder says, "The difficulty with this approach is that not all women who have headache with menstrual period have regular periods, making it difficult to know when to start the regimen. But for women with predictable periods and who routinely have headaches with them, this it is an effective strategy, and one that can be combined with acute treatment."

Continuous hormonal treatment

Occasionally, women with regular periods are not helped by acute treatment or prophylaxis. As a last resort, these women may try continuous hormonal treatment with an extended-duration contraceptive, such as intramuscular depot medroxyprogesterone acetate, subdermal etonorgestrel, oral desogestrel, or a levonorgestrel IUD.

Dr Loder cautions that this off-label treatment approach should be reserved for women who have not benefited from other aggressive attempts at treatment and are very disabled by their headaches, as well as those who understand the potential risks and who have regular and predictable headaches in association with their period.

"Although we think it is the drop in oestrogen that makes women more likely to have headaches, adding oestrogen back is not as simple as it sounds," she explains.

"Oestrogen therapy can have bad side effects. And how it affects the risk of breast cancer is unknown."

The exception is women who are taking hormones for other reasons, such as contraception. If these women have headaches during the hormone-free week they are good candidates for a pill given continuously, to eliminate the drop in oestrogen.

References

Loder EW. "Menstrual migraine: pathophysiology, diagnosis, and impact." Headache. 2006 Oct;46 Suppl 2:S55-60.

Loder EW. "Prophylaxis: headaches that never happen." Headache. 2008 May;48(5):694-6.

Loder E, Rizzoli P, Golub J. "Hormonal management of migraine associated with menses and the menopause: a clinical review." Headache. 2007 Feb;47(2):329-40.

Loder EW. "Menstrual migraine: pathophysiology, diagnosis, and impact." Headache. 2006 Oct;46 Suppl 2:S55-60.

MacGregor, EA, Menstrual migraine: a clinical review. J Fam Plann Reprod Health Care 2007;33(1):36-47.

Pringsheim T, et al. "Acute treatment and prevention of menstrually related migraine headache: Evidence-based review." Neurology 70: 1555-1563.

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READERS' COMMENTS

This hurts more than you think
Posted by owwwch, Venice, USA on Tuesday 6 October 2009 at 06:15 UAE time


Migranes brought on by menstruation are shown to be nearly twice as painful as normal migranes, and 9x more painful than a normal headache. Not a joke.





Menstrual Cramp Remedies

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