Menstrual Migraine: Your Monthly Headache

“Why do I get menstrual migraine attacks?” 

Do your migraine attacks coincide with your period? Hormones have a powerful effect on our minds and bodies, and often play a key role in the migraine experience for women. Many women experience the onset of migraine during puberty, as they begin to produce more of the hormone estrogen. The estrogen itself may not be a catalyst for migraine attacks, but rather its dramatic fluctuations throughout the monthly cycle.

Menstrual migraine is a specific type of migraine triggered by that monthly drop in estrogen levels. Even though a hormone drop is a normal occurrence, the sensitive migraine brain may overreact by unleashing an overwhelming response.

Menstrual migraine attacks are often more disabling, longer-lasting, and harder to treat than non-menstrual migraine. You’ll know you are experiencing a menstrual migraine if it occurs two days before or up to three days into a menstrual period. 

Managing Menstrual Migraine

Coordinate care: Women need to engage both their gynecologist and neurologist to make sure that everyone is informed and in agreement about treatment. 

Keep a calendar: Document the dates you get your period and your symptoms, and bring your calendar with you to your doctors’ appointments so they can see any connections with your migraines. 

This is also true for women who are perimenopausal (the time period before menopause); your irregular periods are a sign that your hormones are changing, which may affect the frequency and intensity of your migraine attacks.

Maintain a healthy lifestyle: Consistency is the best protection against migraine. Eat a healthy and balanced diet, don’t skip meals, stay hydrated, get enough sleep, keep a consistent sleep schedule, and be sure to maintain an exercise regimen. All of these steps add up to improve your overall health.

• • Tip: Stress management is an important part of migraine care. Various types of mindfulness and relaxation training can be a big help, including biofeedback, which helps you learn how to “turn down the dial” on pain.

Effective acute treatment. Treat symptoms early and aggressively, as menstrual migraine attacks are often more resistant to medication. If regular non-steroidal anti-inflammatories (Advil, Aleve, etc.) aren’t effective, the next step may be prescription medicine.

• • A class of medication called triptans (also used for common migraine) are often the most effective in stopping a menstrual migraine attack.
  • Women who experience their worst headaches during menses are more likely to need multiple medications. Some take an over-the-counter medicine in the morning and a more powerful, sedating triptan at night.
  • A migraine that persists despite those medications may require a rescue medicine, such as a Toradol injection.
    • Tip: If during your period you have significant changes in sleep, energy, and/or mood, discuss these changes with your doctor, as migraine and menses can impact sleep and mood in different ways. Consult your doctor if your mood symptoms remain even after a headache has been treated. It may be a sign of other problems such as premenstrual dysphoric disorder.

Prevention: Women whose menstrual migraine attacks are harder to manage with acute treatment may opt for a preventive method:

• • Low-dose oral contraception: Reducing the wild hormonal swings of the menstrual cycle can help reduce the frequency and severity of menstrual migraine. In some cases, doctors may prescribe continual birth control to prevent menstruation altogether, thus preventing headaches that would have occurred during those skipped periods.
    • • Low-dose oral contraceptives may not be recommended for those with risk factors for stroke (high blood pressure, smoking, obesity, diabetes).
      • Because migraine with aura slightly increases the risk for stroke, there has been concern over the use of estrogen-containing contraception in women with migraine with aura. However, neurologists now agree that contraception with a low dose of estrogen (20 micrograms) is safe in women with aura who have no other stroke risk factors. You should consult with your doctor about this option.
  • Hormone replacement therapy: If your menstrual migraine attacks are worsening during perimenopause or menopause, an estrogen skin patch could keep your levels steady.
  • Botox: An injection can last up to three months and can significantly reduce the number of pain medications that you would be taking otherwise.  
  • Prescription medications: Many medicines used to prevent migraine are also effective for menstrual migraine.
    • For patients with predictable menses, some doctors may prescribe a preventive triptan (an acute medication) to be taken every day, starting one to two days before the start of the period, to help ward off or reduce the severity of migraine.
  • Non-medical treatments: Several non-medical techniques can help provide acute relief.
    • Acupressure can relieve symptoms, including nausea and pain, and can be self-administered. 
    • Relaxation techniques can lower stress with breathing exercises and guided imagery.
    • Neuromodulation devices have also been shown to offer acute relief from migraine attacks. These are non-invasive treatments applied to the skin that influence nerves on pain pathways in the brain. 

• The “Bright Side” Of Menstrual Migraine?

  There’s one silver lining to menstrual migraine attacks: Unlike many other types of migraine, at least you generally know when they’re coming. Take advantage of this predictability to plan in advance and prepare for your own care. That’s a powerful way to gain some control over your migraine.