The Menstrual Migraine
Up to 12 percent of female migraineurs (and over 12 million American women) meet the clinical criteria for what is known as menstrual migraine — migraine that is specifically and exclusively tied to the menstrual cycle. This differs from menstrually related migraine, migraine that can be caused by hormonal changes related to menstruation but that also appears at other times in response to different triggers. Approximately half of women with migraine are estimated to have menstrually related migraine.
My migraines happen during my period and also when I'm stressed. Do I have menstrual migraine?
Since you have at least one other identified trigger that is not associated with your menstrual cycle, it's more likely that you have menstrually related migraine.
According to the International Headache Society (IHS), the diagnostic criteria for menstrual migraine is as follows:
Attacks occur exclusively between two days prior to or three days following the start of menstruation in at least two out of three menstrual cycles.
Attacks do not occur at any other time of the cycle, except as noted above.
Headache attacks last four to seventy-two hours (untreated or unsuccessfully treated)
Headache has at least two of the following characteristics:
• Primarily felt on one side of the head (although referred pain may be felt anywhere on the face or head)
• Pulsating or throbbing quality
• Moderate to severe pain intensity
• Aggravation by or causing avoidance of routine physical activity (e.g., walking or climbing stairs)
During headache at least one of the following occurs:
• Nausea and/or vomiting
• Sensitivity to light and sound (photophobia and phonophobia)
Not attributed to another neurological or physical disorder
Most women who have diagnosed menstrual migraine do not experience aura. However, women can also experience migraine with aura that is triggered by hormonal changes related to their cycle.
Menstrual migraine is most likely tied to the drop of estrogen levels that occurs just prior to and during menstruation.
When a menstrual migraine begins after menstruation starts and is associated with dysmenorrhea (or painful cramping during menstruation), it may be caused by an increase in prostaglandin levels. Prostaglandins are the hormones that cause uterine contractions (i.e., cramping). They also set off a variety of physiological changes — including vasoconstriction and sensitization of pain receptors — that can trigger a migraine.
Cyclic prophylaxis doesn't work for everyone. Women with irregular menstrual cycles who can't accurately predict the start of their period may benefit from long-term prophylactic treatment.
Because menstrual migraine is predictable by definition, prophylactic drugs taken around the menstrual cycle can work well. This type of treatment is called cyclic or miniprophylaxis and involves starting medication several days before menstruation and continuing into the menstrual cycle for as long as one week. Triptans appear to be highly effective for this purpose. Taken two days prior to the beginning of menses and continued throughout the cycle, triptans can reduce migraine attacks significantly.
Some nonsteroidal anti-inflammatory drugs (NSAIDs) have also proven effective as a prophylactic. One trial examining a twice-daily regimen of naproxen sodium starting seven days before menses and ending six days into the cycle helped to reduce headache pain, duration, and acute medication use. And in 33 percent of the women studied, it prevented migraine completely.
Cyclic use of transdermal estrogen patches has also proved effective in preventing menstrual migraine in some women. Use of the patch helps to facilitate consistent levels of estrogen in the body during the menstrual cycle.
Triptan drugs and analgesics such as NSAIDs can also be taken for acute treatment of migraine pain. For more on acute treatment of migraine, see Chapter 7, and for more on triptans and NSAIDs as prophylactics, see Chapter 8.
I've never had migraines, but I heard going on birth control pills can cause them! Is that true?
Yes. According to the National Institute of Neurological Disorders and Stroke (NINDS), among women who have never experienced migraines and who start oral contraceptives, the risk of migraine increases tenfold. Talk to your health care provider about the risks and benefits of oral contraceptives for you.
