Menstrual Migraine

1. See Also
   1. Migraine Headache
2. Pathophysiology
   1. Estrogen withdrawal precipitates Headache
   2. Headaches often improve in pregnancy
   3. Associated conditions
      1. Premenstrual Syndrome
      2. Dysmenorrhea
3. Symptoms
   1. Headache onset :2 days prior to Menses
   2. Headache lasts until final day of Menses
4. Associated Conditions: Cerebrovascular Accident
   1. See Cerebrovascular Accident Risk in Women
5. Management: Acute
   1. See Migraine Headache Management
   2. Most effective agents used to abort Menstrual Migraine Headaches (with current body of evidence)
      1. Sumatriptan
      2. Rizatriptan
      3. Mefanamic Acid (Ponstel)
6. Management: Prevention
   1. See Migraine Prophylaxis
   2. Protocol
      1. Start 3 days prior to expected first day Menses
      2. Continue until Menses is finished
      3. Medication Option 1: Long acting Triptans
         1. Frovatriptan (Frova) or Naratriptan (Amerge) taken around the clock perimenstrually
            1. Alternatives include Ergotamine 1 tab bid (significant adverse effects) or Migranal (DHE Nasal)
         2. Naprosyn 500 mg bid
            1. or mefenamic acid (Ponsetl), especially if Dysmenorrhea coexists
         3. Consider Magnesium Supplementation
      4. Medication Option 2: Hormonal cycling
         1. Low estradiol preparations (20 mcg or less)
            1. Loestrin 24 Fe
            2. Microgestin 1/20
         2. Estradiol patch started 2-3 days prior to Menses (see CVA precautions below)
            1. Climara 1-2 patches over 1 week
            2. Estraderm or Vivelle 2-4 patches over 1 week
         3. Consider adding Methyltestosterone 20 mg
   3. Protocol: Continuous OCP cycling with low Estrogen pills
      1. Options: See Seasonal Contraception (or Lybrel, Lo-Seasonique)
      2. Counsel patients on Cerebrovascular Accident risk
         1. Cerebrovascular Accident Risk in Women
         2. Stop Oral Contraceptives immediately if development of Migraines with aura or other changes
         3. Ethinyl Estradiol doses of 20 mcg or less appears safe if no contraindications (see below)
      3. Contraindications
         1. Migraine with Aura
         2. Migraine without Aura and one of the following
            1. Age >35 years old (relative contraindication)
            2. Comorbid Tobacco abuse
            3. Hypertension
7. References
   1. (2012) Presc Lett 19(3): 14
   2. Fettes (1997) Postgrad Med 101(5): 67-77
   3. Matharu (2002) Practitioner 246:272-8
   4. Pringsheim (2008) Neurology 70(17): 1555-63
   5. Silberstein (1995) Postgrad Med 97(4):147-53