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Menstrual migraines develop around a person’s menstrual period, typically manifesting a couple of days before or after the start of menstrual flow.
These headaches are pulsating, typically one-sided, and associated with nausea, vomiting, and light/sound sensitivity. Sometimes, an aura (reversible neurological symptoms) precedes the headache.
What makes menstrual migraines unique and particularly disabling compared to other migraine types is that they tend to last longer and are more severe and resistant to treatment.
This article will review the estrogen and menstrual migraine connection and how menstrual migraine attacks can be treated and possibly prevented.
Menstrual Migraine, Estrogen, and Contributing Factors
Menstrual migraine is common, affecting nearly 17% of menstruating people with migraine.
The two types of menstrual migraine are:
- Pure menstrual migraine occurs only during the five-day perimenstrual window, which begins two days before the start of menstrual flow and ends around day three of a person’s period.
- Menstrually related migraine occurs during the perimenstrual time frame or at other times in the menstrual cycle.
The origin of menstrual migraines is believed to stem mainly from the sudden drop in estrogen levels occurring just before menstrual flow.
This theory that declining estrogen levels serve as a migraine trigger is further supported by the fact that during pregnancy—when estrogen levels are high—migraine-prone people often experience a “break” from their migraine attacks.
Fluctuating estrogen levels also appear to play a role in migraine manifestation. This may explain why some people develop migraines at other times during their menstrual cycle or in perimenopause, the years leading up to menopause, when estrogen levels rise and fall irregularly.
Migraines Tend to Improve After Menopause
Menopause is the time when a person who menstruates stops menstruating for 12 months in a row. It’s characterized by low but stable estrogen levels, which is why migraine attacks usually diminish.
How declining or fluctuating estrogen levels provoke a migraine is not fully understood.
Experts know estrogen receptors (docking sites) are located on trigeminal nerve fibers, which are responsible for conveying migraine pain information to the brain. The functioning of these trigeminal nerve fibers may be sensitive to estrogen variations.
Another possible mechanism is that declining or erratic estrogen levels could cause a decrease in serotonin levels. Serotonin is a brain chemical that has a protective role in migraine attacks and whose function is enhanced by estrogen.
What to Do When a Menstrual Migraine Strikes
Migraine headaches, including menstrual migraines, often improve by resting in a dark, quiet room and taking medication right at the start of the attack.
Other self-care strategies to consider when a menstrual migraine strikes are:
- Place a cool cloth or ice pack on your head or neck.
- Drink water, especially if vomiting is present.
- Avoid aggravating substances or activities like alcohol or exercise.
- Gently stretch your neck muscles.
While initial treatment of most migraine headaches generally starts with an over-the-counter painkiller such as Tylenol (acetaminophen) or Advil or Motrin (ibuprofen), since menstrual migraines tend to be quite severe, triptans are often considered first-line treatment.
What Are Triptans?
Triptans are a class of prescription drugs that target serotonin docking sites in the brain. They work to disrupt the release of inflammatory chemicals and proteins that cause migraines.
The triptan Maxalt (rizatriptan) provides the best overall evidence for treating menstrual migraines, providing prompt and effective pain relief.
Maxalt is available as a pill or a tablet that dissolves on the tongue (called an orally disintegrating tablet, or ODT).
Other triptans used to treat menstrual migraines include:
- Imitrex (sumatriptan): Available as a pill, shot given underneath the skin, nasal spray, or suppository (inserted rectally)
- Zomig (zolmitriptan): Available as a pill, ODT, or nasal spray
- Amerge (naratriptan): Available as a pill
If a person cannot take or tolerate a triptan, other acute migraine medications may be considered, such as:
- A drug that differs from triptans but also targets serotonin, Reyvow (lasmiditan)
- A calcitonin gene-related peptide (CGRP) blocker, like Nurtec ODT (rimegepant), Ubrelvy (ubrogepant), or Zavzpret (zavegepant)
Furthermore, if the migraine attacks are associated with significant nausea or vomiting, an antiemetic drug such as Reglan (metoclopramide) or Compazine (prochlorperazine) may be used with the painkiller.
Speak with a healthcare provider before taking a new medication (OTC or prescription), vitamin, or supplement to avoid potentially harmful side effects or interactions.
Can You Prevent Menstrual Migraines?
Like other migraine types, medication (in some cases), engaging in healthy lifestyle behaviors, and nonhormonal trigger avoidance can help prevent menstrual migraines.
People are generally candidates for preventive menstrual migraine medication if they experience frequent and debilitating migraine attacks or do not obtain sufficient relief from acute therapies.
There are two medication approaches to preventing menstrual migraines: short- and long-term prevention strategies.
Short-Term Preventive Medications
Short-term preventive medications can be used in people with regular, predictable menstrual cycles.
Medications are taken at the time an individual is at risk for a menstrual migraine, typically one to two days before menstrual flow and continuing for around five days.
The mini-preventive medications often used for menstrual migraines are:
Long-Term Preventive Medications
Long-term preventive medications are generally reserved for people with irregular periods or who fail to respond to mini-preventive medications. Those who experience migraine attacks outside their menstrual period may also benefit.
One long-term migraine preventive strategy is taking combination birth control pills continuously (with no break for menstrual flow).
Combination birth control pills—commonly called “combo pills” or “the pill”—release estrogen and progestin (a synthetic version of the hormone progesterone) into the body.
Although studies are limited, results have found that combo pills lower the number of menstrual migraines, presumably by maintaining stable estrogen levels in the body.
Other combination birth control methods that may be used for menstrual migraines include:
Migraine With Aura: Avoid Estrogen-Containing Contraceptives
People who experience an aura (a sensation experienced at the outset of a migraine) with their migraine (menstrual or non-menstrually related) are advised not to take estrogen-containing birth control, as it poses a risk of stroke.
Another long-term preventive strategy for menstrual migraines is taking a daily nonhormonal preventive drug. This strategy is reasonable for someone who has severe or disabling menstrual migraine attacks but cannot take or prefers not to take hormonal contraception.
There are several types of migraine preventive drugs. Two classes of medicines studied for treating menstrual migraines are:
Healthy lifestyle behaviors such as the following can also help prevent menstrual migraine headaches:
- Exercising 30 to 60 minutes three to five times a week
- Eating well-balanced meals at least three times a day
- Drinking seven or eight 8-ounce glasses of water per day
- Sticking to a regular sleep schedule
- Minimizing the effects of stress—consider progressive muscle relaxation or biofeedback
Avoiding nonhormonal triggers (e.g., skipping meals) is another valuable strategy for menstrual migraine prevention. This is because other triggers, combined with fluctuating estrogen levels, may provoke a migraine around a person’s period.
Keeping a migraine diary is a helpful strategy for identifying personal migraine triggers.
How Long Do Menstrual Migraines Last?
Migraine attacks last between four and 72 hours. However, menstrual migraines sometimes last beyond three days, another aspect of their disabling nature.
Be sure to see a healthcare provider or headache specialist if your menstrual migraines are occurring more frequently, lasting longer than usual, or worsening in intensity.
Moreover, see a healthcare provider if you are pregnant, postpartum, or breastfeeding. You may need to change your migraine medication. A provider will also want to rule out other causes of your headaches.
Secondary Effects of Menstrual Migraines
Menstrual migraines, especially during the perimenstrual window, can significantly impair functioning at home, work, or school.
Unfortunately, absenteeism from classes, missed work, or incomplete tasks and assignments can increase stress and contribute to negative emotions like sadness, anxiety, anger, and guilt.
Stress and poor emotional health can then amplify migraine’s burdensome impact, creating an exhausting cycle of anticipation and painful attacks.
Communicating with a healthcare provider about the specific effects of migraines on your daily life can help with formulating a treatment plan that addresses all of your needs.
Link Between Menstrual Migraine and PMDD?
Limited research suggests a high prevalence of menstrual migraine in people with premenstrual dysphoric disorder (PMDD), a severe form of premenstrual syndrome (PMS). Symptoms of PMDD include overwhelming sadness, irritability, and nervousness that negatively impact daily functioning.
Menstrual migraine is a subtype that occurs around a person’s menstrual period. Compared to other migraine types, menstrual migraines tend to be longer in duration, more severe, and resistant to treatment. Treatment of an acute menstrual migraine involves self-care strategies like resting in a dark, quiet room and taking medication at the start of the attack, such as a triptan.
Short-term preventive medications (drugs taken one to two days before menstrual flow and continuing for around five days) may be used in people with regular, predictable menstrual cycles. Continuous or daily preventive medication includes hormonal (e.g., combination birth control pills) and nonhormonal options (e.g., Topamax or a CGRP blocker).