Menstrual Migraine

What is Menstrual Migraine?

Migraine occurs predominantly in women and has been found to be influenced by factors such as menarche, pregnancy, use of oral contraceptives and menopause. All these point to a hormonal role in its causation. The original study linking menstrual migraine to dipping hormonal (estrogen) levels was published in Neurology journal in 1972.

Headaches that occur 2-3 days before the onset of periods and during the menstrual flow, which are typically more severe than headaches occurring at other times, and are influenced by bright light could be menstrual migraine.

These headaches are disabling. They are more difficult to treat than other headaches and frequently do not respond to drugs that are effective for other types of headaches. Menstrual migraine affects about ten percent of women.

There are two patterns of menstrual migraine.

• Pure menstrual migraine occurs only in relation to periods. One in seven women suffer from this type of migraine.
• Menstrual-associated migraine occurs around periods as well as other times of the month too. About 60 percent of women suffer from this type of migraine.

What are the Causes of Menstrual Migraine?

Many theories have been proposed to explain the causes of menstrual migraine. These include

• Falling levels of estrogen before the onset of periods. The falling estrogen levels may stimulate facial nerves or alter the blood flow to the brain, thereby causing migraine.
• Increased secretion of prostaglandins that occur during the first two days of periods.

It is also suggested that menstrual migraines may be linked to disordered serotonin metabolism in the body and the manner in which serotonin interacts with female hormones.

What are the Symptoms and Signs of Menstrual Migraine?

Menstrual migraine occurs in about 20 percent of women during their reproductive life. Most of the women report suffering from migraine without aura (MO). An aura refers to sensory visual or auditory symptoms, and weakness that precedes the headache and lasts for anywhere between 5 to 60 minutes.

• Menstrual migraine typically occurs as an intense one-sided throbbing headache that might be accompanied by nausea or vomiting. Aura may or may not be present.
• Associated symptoms include tiredness, joint pain, constipation, decreased urination and impaired coordination.
• Craving for salt, chocolate, and an increased appetite may be present.

How do you Diagnose Menstrual Migraine?

There are no tests to confirm the diagnosis of menstrual migraine, though tests may be performed to rule out headaches due to other causes. The International Headache Society (IHS) has laid down the following criteria for the diagnosis ofpure menstrual and menstrually-related migraine.

Pure menstrual migraine criteria

• Migraine headaches in a menstruating woman, satisfying criteria for migraine without aura
• Attacks restricted to any time between 2 days before and 3 days after start of periods and occur in minimum 2/3 cycles only and not other times during the month

Menstrually-related migraine criteria

• Migraine headaches in a menstruating woman, satisfying criteria for migraine without aura
• Attacks restricted to any time between 2 days before and 3 days after start of periods and occur in minimum 2/3 cycles and also at other times during the month

Criteria for diagnosis of migraine without aura

• At least 5 episodes satisfying criteria B to D
• Headaches last between 4 to 72 hours (untreated or unsuccessfully treated)
• Pain is moderate to severe, unilateral and throbbing and aggravated by activity (any 2/4 should be present)
• Associated with increased sensitivity to light or sound; or nausea and/or vomiting (1 out of the 2 pair of symptoms must be present)
• No other cause for headache found

The patient is advised to maintain a diary for at least 3 months recording details of the all headaches and triggering factors and the dates of her periods. This will help to identify non-hormonal triggers such as dietary factors which can then be avoided.

How do you Treat Menstrual Migraine?

Treatment of menstrual migraine depends on the following

• Severity of the attacks
• Regularity of the periods
• Whether or not there is painful periods and cramps
• Whether the patient wants contraception

One or more of the following treatment strategies may be used

• Enhanced acute treatment for an acute attack
• Mini prevention strategies are used for 2 days before and 3 days during the periods
• Continuous prevention are used when mini preventive measures do not work

Treatment of acute attack

Depending on the severity of the attack, an acute episode can be treated with oral medications, injection or in the form of a nasal spray.

Mild attack

A fast acting triptan sumatriptan, zolmitriptan, rizatriptan, almotriptan, or eletriptan, taken orally early in the migraine, along with a nonsteroidal anti-inflammatory drug (NSAID) such as naproxen or ibuprofen usually controls the headache and other symptoms.

Moderate to severe attack

When the migraine is severe and associated with nausea and vomiting, oral pills may not be beneficial. An injectable triptan such as sumatriptan (the only injectable triptan available) is preferred. It is available as both needle and needle free syringes. It gives relief in about 10 minutes, and more importantly bypasses the digestive tract.

Another drug that comes in injectable form is dihydroergotamine (DHE). Either a triptan or DHE coupled with an NSAID will offer added relief.

If the patient is unable to take oral pills due to severe nausea or vomiting and does not prefer injections, a nasal triptan such as zolmitriptan can be administered as a spray. It is effective and faster acting than a pill. DHE can also be administered as a nasal spray as 4 sprays over 15 minutes. Also ketorolac, an NSAID is available in a nasal form and approved for moderate-to-severe pain, (not specifically for migraine though), may be beneficial if the patient cannot take triptans due to the presence of an underlying vascular disease or have been proven ineffective.

Mini-prevention strategies

If periods are regular:

• Usually an NSAID taken for 2 days before and 3 days during the period has been shown to be effective. If the periods are painful and associated with cramping, mefenamic acid is preferred as it is effective in reducing both migraine as well as painful periods.
• Triptans have also been found to be as effective as mini-preventive strategy but there are concerns that the headaches become more frequent at other times of the month and often more severe.
• Hormonal estrogen supplements in the form of pills, cream or skin patch given during the menstrual week have been shown to be effective by preventing the fall in estrogen levels before periods. This regimen is effective in the presence of regular cycles, and especially if the patient is on oral contraception. In the week when the patient is off the oral pill or the vaginal ring is removed, estrogen is supplemented as a pill, gel or as skin patch.

If periods are not regular:

NSAIDs or triptans may be started on day 1 of the period and have been shown to be effective. Magnesium has also been used starting from day 15 of the menstrual cycle till the onset of bleeding.

Even if migraine occurs while following the mini-preventive strategy, the attacks are less severe and can be easily controlled with an oral triptan.

How can you Prevent Menstrual Migraine?

In women with irregular periods and in whom mini strategy does not control the headaches, continuous preventive strategy may be effective.

• Administration of oral contraceptive pills continuously such that there is no break for periods may be effective in preventing menstrual migraine. Usually a break from the hormonal treatment is given once in every 3 to 6 months during which mini-preventive strategies may be used or aggressive treatment of migraine attacks is given.

Oral contraceptive pills should not be used if the woman is trying to get pregnant or if the migraines are associated with aura since there is an increased risk of stroke.

Also, contraceptive pills are not the preferred option in women over 35 years of age, those with high blood pressure, high cholesterol, diabetes or smokers.

• Salt restriction in the days leading up to the period may reduce the frequency or severity of menstrual migraine.

• Dietary modifications - Avoiding refined sugar, processed foods, migraine trigger foods, monosodium glutamate (MSG), aspartame and hydrolyzed vegetable protein may help to reduce menstrual migraine attacks.
• Getting adequate sleep and reduction of stress.

References:

1. Headaches and hormones: What''s the connection? - (http://www.mayoclinic.org/diseases-conditions/chronic-daily-headaches/in-depth/headaches/art-20046729)
2. About Menstrual migraine - (https://www.migrainetrust.org/about-migraine/types-of-migraine/menstrual-migraine/)
3. What is Menstrual migraine? - (http://www.headaches.org/2007/10/25/menstrual-migraine/)
4. Migraine in women: the role of hormones and their impact on vascular diseases - (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3311830/)

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