Management of Menstrual Migraine

Acute Treatment Strategy

The American College of Neurology recommends using NSAIDs as initial treatment for mild-to-moderate menstrual migraine attacks, with ibuprofen 400-800mg every 6 hours, naproxen sodium 275-550mg every 2-6 hours, or diclofenac potassium as effective options 1, 2
Administer acute therapy early when headache is still mild in severity to maximize effectiveness 1, 2
Escalate to triptans when NSAIDs provide inadequate relief, with sumatriptan 50-100mg, rizatriptan 10mg, or combination sumatriptan/naproxen 85mg/500mg as proven effective options 1
Never use triptans during the aura phase—they are ineffective and should only be used when headache begins 1
Avoid opioids and barbiturates due to dependency risk, rebound headaches, and poor efficacy 1, 2
Avoid oral ergot alkaloids due to poor efficacy and potential toxicity 1

Implement perimenstrual prophylaxis when acute treatment alone is insufficient to control menstrual migraine attacks 1
Frovatriptan 2.5mg twice daily is the mainstay of short-term prevention, started 2 days before expected menstruation and continued for 5-6 days 1
Naratriptan 1mg twice daily using the same timing is an alternative option 1
Long-acting NSAIDs like naproxen can also be used perimenstrually for 5 days beginning 2 days before expected menstruation 1, 2

Use daily preventive medications for women with frequent migraines throughout the month, not just during menstruation 1, 2
Beta-blockers (propranolol 120-240mg daily, metoprolol, atenolol, bisoprolol) as first-line daily preventive therapy 1, 2
Topiramate 50-100mg daily as an alternative first-line option 2
Candesartan as another first-line choice 1

Continuous use of combined hormonal contraceptives can benefit women with pure menstrual migraine without aura by eliminating the hormone-free interval 1, 2
Absolutely contraindicated in women with migraine with aura due to increased stroke risk 1, 2

Prokinetic antiemetics (domperidone, metoclopramide) can be used for associated nausea and vomiting 1

Evaluate treatment response within 2-3 months after initiation or change in treatment 1, 2
Use headache calendars to track attack frequency, severity, and medication use 1, 2
Consider the Migraine Treatment Optimization Questionnaire (mTOQ-4) to evaluate effectiveness of acute medications 1
Monitor for medication overuse—limit triptan use and educate patients on rebound headache risk 1
If one preventive treatment fails, try another drug class as failure of one does not predict failure of others 1