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A National Migraine Centre factsheet
Studies show that migraine is most likely to occur in the two days leading up to a period and the first three days of a period – this is commonly referred to as ‘menstrual migraine’. Most women have migraine attacks at other times of the month too, but a few have migraine only with their periods.
Menstrual migraine attacks are typically more severe, last longer, and are more likely to recur the next day than non-menstrual attacks. This means that many women who find that their migraine treatment works well most of the time may still have a problem with managing their menstrual migraine attacks. Characteristically, these attacks are without aura.
50 to 60 per cent of women notice a link between their migraine and periods. This may not be apparent until a woman reaches her late thirties or into her forties, even for those who may have suffered migraine from a younger age.
Women with other period problems often don’t recognise that the accompanying headaches are actually migraine. This under-recognition of migraine by patients is compounded by a similar under-recognition of migraine by doctors.
Studies have shown that migraine can be triggered by a drop in oestrogen levels, such as naturally occurs around menstruation.
Oestrogen ‘withdrawal’ also triggers migraine in other situations, such as the pill-free interval of combined oral contraceptives.
However, oestrogen is not the only hormone responsible for menstrual migraine. Other studies have shown that women who notice migraine during the first few days of their period may be susceptible to the effect of the hormone prostaglandin.
This hormone is at its highest level in the body during a period, particularly in women who have heavy or painful periods, and can be associated with headache.
Research is ongoing as it’s quite likely that there are other causes for menstrual migraine too. The menstrual cycle is complex and involves a number of brain chemicals known as neurotransmitters that alter the effect of hormones such as oestrogen, and others linked to migraine such as serotonin.
Keeping a headache diary for at least three menstrual cycles can be very helpful. This will help to confirm the relationship between your migraine and periods.
You can use our simple headache diary, which you can find here.
You might worry that you should have some investigations, such as a test of your hormones or a brain scan. These tests are usually only necessary if your doctor thinks the problem is something other than migraine. There’s unlikely to be anything notable about your hormones, the difference is just that you are more sensitive to normal hormone fluctuations.
Migraine typically worsens as you get closer to the menopause (the so-called perimenopause), partly because periods come more often and partly because the normal hormone cycle becomes disrupted.
The good news is that once periods stop and the hormones settle down, migraine improves. You can find out more about migraine and the menopause in our factsheet.
Most women with migraine can manage menstrual migraine attacks in the same way as non-menstrual migraine – you’ll find plenty of tips and advice across our other National Migraine Centre factsheets.
Keeping a headache diary can help you to anticipate when your period is due.
Look especially at the non-hormonal migraine triggers as avoiding these ahead of your period may be sufficient to prevent what appears to be a hormonally linked attack.
For example, take care not to get overtired and, if necessary, cut out alcohol. Eat small, frequent snacks to keep blood sugar levels up, as missing meals or going too long without food can trigger attacks.
Treat an attack with your usual medication and don’t delay – treatment is more effective when taken early. If the migraine attack returns later the same day or the next day, repeat the treatment. This can sometimes go on for four or five days around period time.
If your headache diary confirms that your attacks always occur within two or three days around the start of your period, your doctor may consider ways to prevent migraine. Preventative treatments are often less effective in women who also have attacks at other times of the cycle resulting from non-hormonal triggers.
Depending on the regularity of your menstrual cycle, whether or not you have painful or heavy periods, menopausal symptoms, or if you also need contraception, several different options might be tried.
Although none of the drugs and hormones recommended below are licensed specifically for the management of menstrual migraine, doctors can prescribe them for this condition if they feel that this would be of benefit to you.
Mefenamic acid is an effective migraine preventative and has been reported to be particularly helpful in reducing migraine associated with heavy and/or painful periods, although no clinical trials have been undertaken specifically for menstrual migraine. A dose of 500mg, three to four times daily, may be started two to three days before the expected start of your period – but it is often effective even when started on the first day, which is useful if periods are irregular. Treatment is usually only necessary for the first two to three days of your period.
Naproxen has also been found to be effective at doses of around 500mg once or twice daily around the time of menstruation.
Unless a woman also needs contraception, supplementing oestrogen for several days around the time of your period (perimenstrual treatment) can prevent the natural oestrogen drop that can trigger migraine. Perimenstrual oestrogen supplements can only be used when your periods are regular and predictable.
Oestrogen patches in a dose of 100mcg can be used from around five days before you expect your period to start and up to the fifth day of menstruation. The dose should be tapered off for the last few days of treatment by cutting the patch in half. If this is effective but there are side effects (such as bloating, breast tenderness, leg cramps or nausea), a 50mcg dose should be tried for the next cycle. Alternatively, estradiol gel 1.5 mg can be applied daily from around five days before expected menstruation up to the fifth day of menstruation, again tapering off the dose of oestrogen for the last few days of treatment.
More recent evidence shows that oestrogen supplementation is not sufficient in treating menstrual migraine since many women have delayed attacks when the supplements are stopped. Though the treatment can be extended until day seven of the cycle (when a woman’s own oestrogen starts to rise), this option is becoming less popular.
Long-term use of oestrogens for hormone replacement therapy by women after the menopause has been associated with increased risk of breast cancer. In contrast, there is no evidence that supplemental oestrogens used by premenopausal women who are still having natural periods carries the same risks. However, supplemental oestrogens are not recommended for women who are at high risk of breast cancer.
There have been studies into the use of long-acting triptans around the time of menstruation. Although triptans are not licensed for use in this way, your doctor may prescribe if they feel it could be helpful.
Frovatriptan at a dose of 5mg twice a day two days before the expected migraine then 2.5mg twice a day for five days can be useful. Alternatively, naratriptan 1mg per day two days before the expected migraine continued for five days can be tried. Frovatriptan is less likely to cause a delayed headache than naratriptan.
If you need contraception, or your periods are irregular, there are a number of contraceptive strategies that can also help treat menstrual migraine.
Combined hormonal contraceptives (CHC) contain oestrogen and progestogen. The most common one is ‘the Pill’ although weekly patches are also available.
These ‘switch off’ the natural menstrual cycle and maintain fairly stable oestrogen levels for the 21 days of active hormone. However, migraine often occurs during the seven-day hormone-free interval, as oestrogen levels drop.
Doctors are increasingly happy to suggest reducing the number of hormone-free intervals, and so reducing migraine attacks, by taking three or four consecutive packs and then having a shorter four-day break.
Taking CHCs continuously without a break may be even better for some women, if breakthrough bleeding is not a problem. Although this can be an effective strategy for women who have migraine without aura, contraceptive oestrogens should not be used by women who have migraine with aura due to the potential increased risk of stroke. For such women, progestogen-only methods are recommended.
Progestogen-only pill Desogestrel (Cerazette or Cerelle) works in a similar way to combined hormonal contraceptives but does not contain oestrogen. Because the pill is taken every day, without a break, many women do not have periods, although irregular bleeding can be an occasional problem. Unlike Desogestrel, other types of progestogen-only pills do not switch off the cycle and are unlikely to help menstrual migraine.
Injectable ‘depot progestogens’ also work in a similar way to combined hormonal contraceptives and are given every 12 weeks. Although most women having depot progestogens find that their periods stop completely, it can take a few months before this happens. Until then, migraine can occur with bleeding. It’s important to persevere until bleeding settles down, which may not be until the third or fourth injection.
The Mirena intra-uterine system (‘the hormonal coil’), is licensed for contraception but is also highly effective at reducing menstrual bleeding and associated pain. It may be effective in migraine that is related to heavy or painful periods and that has responded to non-steroidal anti-inflammatory drugs such as mefenamic acid or naproxen. It is not effective for women who are sensitive to oestrogen withdrawal as a migraine trigger, since the normal hormone cycle continues.
Hysterectomy has no place solely in the management of migraine. Studies show that migraine is more likely to worsen after surgery. However, if other medical problems require a hysterectomy, which can induce the menopause, the effects on migraine are probably lessened by subsequent oestrogen replacement therapy.
Gonadotrophin-releasing hormones create a medical ‘menopause’ and have been used to assess the likely outcome of a hysterectomy, although symptoms of oestrogen deficiency, such as hot flushes, limit their use. These hormones are also associated with bone thinning (osteoporosis) and should not usually be used for longer than six months without regular monitoring and scans to test bone density. Continuous combined oestrogen and progestogen can be given to counter these difficulties. Given these limitations, in addition to their high cost, this type of treatment is generally only used in specialist departments.
The menopause marks a time of increased migraine. HRT can help, not only by stabilising oestrogen fluctuations associated with migraine, but also by relieving night sweats that can disturb sleep. Unlike oestrogen supplements, which are just used around the time of the period, HRT is taken throughout the cycle. It should only be started when periods become irregular and/or other menopausal symptoms, such as hot flushes, are present. If taken for only a couple of years to control symptoms, there is no evidence of increased risk of breast cancer.
Listen to our Heads Up podcast special episode 1 in series 2 for more information on hormones and migraine.
Book an appointment with the experts: a consultation with a leading headache specialist, with an understanding of women’s health, migraine and menstruation, could help you get on top of migraine. Book your consultation now.
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