Menstrual migraine

A specific condition where the timing of attacks is linked to the menstrual cycle

Whilst many women report that menstruation is a migraine trigger, there is a specific condition known as ‘menstrual migraine’.

Menstrual migraine is associated with falling levels of oestrogen. 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. There is no aura with this type of migraine and it can often last longer than other types. This type of migraine is thought to affect fewer than 10% of women. The two most accepted theories on the cause for menstrual migraine at the moment are:

  1. the withdrawal of oestrogen as part of the normal menstrual cycle and
  2. the normal release of prostaglandin during the first 48 hours of menstruation.

There are no tests available to confirm the diagnosis, so the only accurate way to tell if you have menstrual migraine is to keep a diary for at least three months recording both your migraine attacks and the days you menstruate. This will also help you to identify non-hormonal triggers that you can try to avoid during the most vulnerable times of your menstrual cycle.

Treating menstrual migraine

There are several treatment options depending on the regularity of your menstrual cycle, whether or not you have painful or heavy periods, menopausal symptoms or you also need contraception.  Although none of these options are licensed specifically for menstrual migraine, they can be prescribed for this condition if your doctor feels they would benefit you.

If you have migraine and heavy periods, taking an anti-inflammatory painkiller such as mefenamic acid could help.  Mefenamic acid is an effective migraine preventative and is also considered to be helpful in reducing migraine associated with heavy and/or painful periods.  A dose of 500 mg can be taken three to four times daily.  It can be started 2 to 3 days before the expected start of your period.  If your periods are not regular, it is often effective when started on the first day.  It is usually only needed for the first two to three days of your period.  Naproxen can also be effective in doses of around 500 mg once or twice daily around the time of menstruation.

You may wish to discuss using oestrogen supplements with your doctor. Topping up your naturally falling oestrogen levels just before and during your period might help if your migraine occurs regularly before your period. Oestrogen can be taken in several forms such as skin patches or gel. You put the patch on your skin for 7 days starting from 3 days before the expected first day of your period. Similarly, you rub the gel onto your skin for 7 days. In this way the oestrogen from the patch or gel is absorbed directly into your blood stream. You should not use oestrogen supplements if you think you are pregnant or you are trying to get pregnant. Again keeping a diary of your migraines will help you to judge when best to start the treatment.

If your periods are irregular your doctor may suggest other ways to try and maintain your oestrogen levels at a more stable rate such as a combined oral contraceptive pill.

FAQ: Will having a hysterectomy help menstrual migraine?

In order to answer this question, it’s important to understand the female reproductive organs, i.e. the uterus (womb) and the two ovaries each side of the uterus. The ovaries contain the eggs and also produce the sex hormones oestrogen and progesterone. At the beginning of each menstrual cycle, some of the eggs will start to mature under the influence of hormones produced by the ovaries. In the middle of the cycle, one egg (sometimes more) will ovulate. If the egg is not fertilised it will get absorbed by the body but more importantly the level of hormones fall. This fall of hormones triggers the lining of the womb to break down and be shed through the vagina – called menstruation.

It is this withdrawal of hormones that acts as a trigger in women with menstrual migraine or menstrual-related migraine. So, if someone is considering a hysterectomy to treat menstrual migraine, it would not help as the ovaries would need to be removed.

There are a few diagnoses where for a small minority of women, surgical removal of the ovaries is the only measure that will allow them to continue a normal life. It is a very controversial treatment and is therefore very rare.

The first options are non-surgical ways of putting the ovaries out of action. Once the ovaries are out of action (in whatever way) the woman must take hormone replacement therapy until the average age of menopause (age 55) to prevent the long term consequences of oestrogen deficiency (e.g. risk of osteoporosis).

One way to suppress the hormonal cycle is to use different forms of hormonal contraception. The combined contraceptive pill, one progestogen-only pill, the progestogen-only injection and implant will work by stopping ovulation.

Migraine and the premenstrual syndrome

Premenstrual syndrome (PMS) affects between 70% and 90% of fertile women. Migraine and headaches can occur as part of the PMS alongside other symptoms of PMS such as sore breast, low mood and feeling irritable. To determine if your migraine is part of PMS you will need to keep a diary card for at least three menstrual cycles. In this way you can see if you have a pattern of symptoms during the second half of your menstrual cycle which reduce when the bleeding starts.

Treating migraine attacks associated with PMS

The effectiveness of drug treatment for PMS is limited and there is little clinical evidence available. If you suffer from PMS and migraine you may be best to start managing the PMS through other routes such as lifestyle changes and relaxation. You may find that it helps to eat frequent and small carbohydrate based snacks as there is some evidence to suggest that some women benefit from maintaining constant glucose levels before their period starts. You should consider treating your migraine with medication whilst you see if your PMS can be better managed.