A 26-year-old female presents with throbbing unilateral headaches with an 8/10 intensity. They are associated with photophobia, phonophobia, nausea, and vomiting. She denies visual, sensory, language, or motor disturbances suggesting aura.
Individual attacks last 6–24 hours, and she estimates having seven headache days per month that tend to have a strong menstrual association. The majority of headaches begin two days prior to the onset of her menstrual cycle, and continue three days into menstruation. Her menstrual cycles are regular, occurring at 28-day intervals.
She has no other medical problems, and is not taking any medications. She has no allergies, and denies any tobacco or illicit drug use. There is a family history of migraines involving her mother and maternal grandmother. Her neurological examination was unremarkable.
What do you do now?
At first glance, her diagnosis is seemingly obvious: migraine. The description of her headache fulfills criteria for episodic migraine without aura.1 Migraines that have a menstrual association are further classified as pure menstrual migraine without aura, or menstrually related migraine without aura (Box 3.1). In this case, the patient has menstrually related migraine without aura, as this patient experiences some migraines outside of her menstrual periods.
The prevalence of menstrually related migraine can range from 20–60%, while pure menstrual migraine occurs in less than 10% of women.8 Menstrual migraine attacks are typically not associated with aura symptoms. They tend to be more severe, longer lasting, more resistant to treatment, and associated with higher rates of functional disability.2
A diary documenting migraines and menstrual cycles should be kept over the course of three consecutive cycles. A diagnosis of menstrually related migraine can be confirmed when two of those menstrual cycles correlate with migraine onset within –2 to +3 days of menses. In contrast to sufferers of pure menstrual migraine, menstrually related migraine patients also have attacks at other points in their cycle.
Studies evaluating the relationship between the onset of migraine attack and its correlation to menstruation demonstrated a strong association with the natural drop in estrogen during the late luteal phase of the menstrual cycle. For women who have regular cycles and in whom a diagnosis of menstrually related migraine has been made, spot prophylactic or perimenstrual prophylactic treatment may be indicated. Prophylactic options can include nonsteroidal anti-inflammatory drugs (NSAIDs), triptans, and hormonal options.5,6,7
Medication dosage options include:8
• Naproxen sodium 550 mg twice daily for 5–14 days, starting the week before anticipated period onset.
• Frovatriptan to be started two days before period onset, with 5 mg taken twice daily on day 1, then 2.5 mg twice daily for six days.
• Naratriptan 1 mg twice daily for six days to be started three days before period onset.
• Zolmitriptan 2.5 mg twice or three times daily for seven days starting two days before expected period onset.
Hormonal options, such as estrogen supplementation, are geared to maintaining steady levels of estrogen, thus forestalling the abrupt drop that occurs during the late luteal phase. Since estrogen-based contraceptives are associated with an increased risk of stroke, and patients who suffer from migraine with aura carry a slightly increased risk of stroke, physicians should consider the use of progesterone-only formulations.
Key Points to Remember
• Menstrually related migraines tend to be longer lasting, more debilitating, and more resistant to standard acute treatments than non-menstrual migraines.
• The diagnosis of menstrual migraine is made based on history, physical examination, and analysis of headache diaries demonstrating a menstrual relationship to headache in two out of three menstrual cycles. This diagnosis should be made after secondary headaches have been ruled out.
• Pathophysiology of menstrual migraine is thought to be related to the abrupt drop in estrogen in the late luteal phase and an increase in prostaglandins.
• Perimenstrual prophylaxis with NSAIDs, triptans, or hormones may be beneficial in reducing frequency and intensity of menstrually related migraine attacks.
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7.Macgregor EA. Contraception and headache. Headache. 2013;53(2):247–276. doi:10.1111/head.12035Find this resource:
8.Macgregor EA. Migraine management during menstruation and menopause. Continuum. 2015;21:990–1003. doi:10.1212/con.0000000000000196Find this resource: