What is a Menstrual Migraine?

If you find that your migraines occur most frequently right before or at the start of menstruation and that these migraine attacks last longer, are more severe and are less responsive to typical migraine pain-relief medications, you are not alone.

There are two types of menstrual-related migraines:

• Pure menstrual migraine without aura
• Menstrually-related migraine without aura.

If you have pure menstrual migraines without aura, your attacks occur exclusively during the perimenstrual period. This means they begin two days prior to your menstrual cycle up until three days after the onset of menstruation. To technically have a pure menstrual migraine without aura, a woman must experience these migraine attacks in two out of three menstrual cycles and at no other time.

Similar to a pure menstrual migraine without aura, a menstrually-related migraine without aura occurs during the perimenstrual period in at least two out of three menstrual cycles. But with this type of a migraine, a woman can also have migraines without auras during other times in her cycle, like during ovulation, for example.

According to the American Headache Society, the prevalence of pure menstrual migraine without aura occurs in 7 to 19 percent of women with migraines. A menstrually-related migraine without aura occurs in 35 to 51 percent of females with a migraine. In other words, menstrual migraines are common.

The most likely reason has to do with the decline in estrogen that occurs just prior to menstruation. More specifically, the presence of estrogen is associated with increased levels of serotonin in the brain. In other words, a decline in estrogen implies a decrease in serotonin.

This is important because serotonin is linked (in a complex way) to a person's trigeminovascular pain pathway, and this pathway is believed to play a vital role in migraine formation.

Another theory about menstrual migraines involves the way women perceive pain, which may vary throughout the course of the menstrual cycle. For example, in one study, pain perception was higher during the premenstrual and menstrual part of the cycle, as opposed to the mid-menstrual or during ovulation.

The triptans, sumatriptan, and rizatriptan have been found to be effective in alleviating menstrually-related migraines. 

Mefenamic acid (Ponstel), a non-steroidal anti-inflammatory (NSAID), was also found to effective. In one study, mefenamic acid, at a dose of 500mg three times daily, was given at the start of a menstrual migraine and then taken for the duration of the menstrual cycle.

Please note that mefenamic acid is a NSAID. NSAIDs have several potential adverse effects and should be avoided by some individuals, particularly those with a history of stomach bleeding, kidney disease, and/or heart disease.

Always discuss any medication you take beforehand with your doctor.

If you get menstrual migraines frequently, your doctor may recommend a preventive medication. Long-acting triptans, like frovatriptan or naratriptan, taken for 5 to 6 days (dosed twice daily) in the perimenstrual period are shown to be effective in decreasing the number of menstrually-related migraines. However, it's important to note that no triptan is FDA approved for migraine prevention at this time.

NSAIDs like Aleve (naproxen) take twice daily during the perimenstrual period may also be useful in preventing or reducing the severity of a menstrual migraine.

Magnesium starting at day 15 of your cycle and continuing until menses begins may also be effective. Lastly, estrogen supplementation or continuous birth control may also be used to prevent menstrual migraines.

There are contraindications to both triptans and estrogen therapy, so please be sure your headache specialists consult your primary care physician to be certain they are safe for you.

It's not uncommon for your migraines to occur at certain times in your cycle, especially in the peri-menstrual period, so don't feel alone. That said, your migraines can be treated effectively—it may just require a bit of patience and trial and error. Speak with your doctor if you notice this pattern as it may affect your treatment plan.