Treating menstrual migraine

Pre-empting headaches can transform the lives of menstrual migraine sufferers.
Treating menstrual migraine
By Partners Harvard Medical International
Wed 31 Dec 2008 04:00 AM

Pre-empting headaches can transform the lives of menstrual migraine sufferers.

Migraine headaches can induce debilitating pain, causing people to miss work or school and negatively affecting their quality of life. Of all types of migraines, those associated with menstruation tend to be the most severe, longest lasting, most disabling, and most difficult to treat.

In fact, according to the World Health Organization (WHO), migraine is among the world's top 20 leading causes of disability. Repeated migraine attacks not only affect a person during an attack but between attacks.

Dr Elizabeth Loder, an associate professor of Neurology at Harvard Medical School and chief of the Division of Headache and Pain in the Department of Neurology at the Brigham and Women's/ Faulkner Hospitals in Boston, observes: "Many chronic migraine sufferers can't make plans or go to social events, because they don't know when they will have their next headache. Although people seem like they are fine between the headaches, they have a decreased quality of life because they are always anxious about when the next headache will arrive."

The long-term effort of coping with chronic migraines may also predispose a person to other illnesses. For example, depression is three times more common in people with migraine or severe headaches than in people without migraine.

During childhood, more young boys have migraine than girls, but this changes at puberty. After puberty, migraine eventually affects women three times more often than men. This sex difference increases with age, peaking during the early 40s, then declining.

Hormones, especially oestrogen, appear to modulate migraine activity. It is now thought that the oestrogen withdrawal that occurs just prior to the onset of menses is the trigger for headaches that occur just before a woman gets her monthly period.

Effective treatments have been shown to reduce the impact of menstrual migraine once an appropriate diagnosis is made. Yet despite the high prevalence of menstrual migraines among women of childbearing age, health professionals routinely fail to effectively diagnose and treat the condition.

Dr Loder explains, "For centuries the focus was on waiting until the headache came, and then taking something to make it better or go away. While that strategy works well for a lot of people, especially those who don't have headaches very often, a sizeable minority have very frequent headaches and, for them, that strategy can backfire."

People who take headache medication frequently may end up with "medication overuse headaches", which can make headaches more frequent. In addition, acute treatment does nothing to address the anxiety endured between attacks.

A more effective strategy for these people involves pre-empting attacks. Most women with menstrual migraine have predictable attacks between two days before and three days after the start of menses.

This allows them to take medication before the headache begins, thereby preventing the attacks or at least lessening their severity.

Dr Loder says, "The idea of stopping the headaches before they begin is a new idea that has transformed the lives of countless headache sufferers."

Behavioural and lifestyle changes

Women with migraine are generally more susceptible to dietary, physical, and environmental triggers for migraine attacks during the week before and the first few days of their period. Some non-pharmacological ways women may prevent migraines associated with these triggers include:

• Eating regularly scheduled healthy meals • Staying hydrated • Getting consistent and regular sleep • Getting regular exercise • Learning stress-reduction techniques• Avoiding dietary triggers (eg. caffeine and alcohol). It's a good idea for these women to keep a food diary to observe any additional trigger foods and avoid them as well.

Most menstrual migraine attacks are the result of several of these triggers building up over the cycle. The menstrual trigger is the final one to trigger an attack.

For some women, eliminating migraine triggers reduces the frequency and severity of all attacks. For others, it only eliminates the non-hormonal attacks while the menstrual attacks persist. Often this approach works best when combined with pharmacological treatment.

Diagnosing menstrual migraine

A headache diary is the most important tool for providing detailed and accurate information about a woman's headaches.

It includes daily information about headaches (severity and duration), medications, menses (or the last day of oral contraceptive) and exposure to triggers. Clinical diagnosis requires a headache diary for at least three consecutive menstrual cycles.

Treating menstrual migraine

Acute treatment

Symptomatic treatment with NSAIDS or triptans is appropriate for people with relatively infrequent, non-disabling headaches and who get reliably good results from the medication, says Dr Loder.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.

Definitions

What is migraine?

Migraine is a recurrent headache that lasts from 4-72 hours. People who suffer from migraines typically experience intense headache, nausea, sensitivity to light and sound, numbness or tingling sensations, dizziness, difficulty thinking, and some level of disability during an attack.

What is menstrual migraine?

Menstrual migraine is a migraine headache that occurs regularly between two days before and the first three days of menstrual bleeding. Pure menstrual migraines occur around two days before and three days after the onset of menstrual flow and at no other times of the month.

Menstrually-related migraines occur within two days before and three days after the onset of menstrual flow and occur at other times of the cycle as well.

Menstrual attacks are without aura. Although about 60% of women who have migraine experience attacks before or during their menstrual period, only about 10 to 15% have pure menstrual migraines.

This article is provided courtesy of Partners Harvard Medical International.

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