Menstrual Migraine Treatment Guidelines

Introduction to Menstrual Migraine

Approximately 8% of women with migraine experience attacks exclusively related to menstruation (pure menstrual migraine), while a larger percentage experience menstrually-related migraines that occur both during menstruation and at other times 1

The American Academy of Neurology recommends perimenstrual preventive treatment with a long-acting NSAID (like naproxen) or triptan (like frovatriptan or naratriptan) for 5 days, beginning 2 days before expected menstruation, for menstrual migraines when acute treatment alone is insufficient 1, 2
First-line medications for acute treatment include NSAIDs (acetylsalicylic acid, ibuprofen, diclofenac potassium) and should be used early in the headache phase for maximum effectiveness 3, 4
Second-line medications for acute treatment include triptans (sumatriptan, rizatriptan, eletriptan, etc.) and can be combined with fast-acting NSAIDs to prevent recurrence 3, 4
Adjunct medications such as prokinetic antiemetics (domperidone, metoclopramide) can be used for associated nausea/vomiting 3, 4
Medications to avoid include oral ergot alkaloids and opioids and barbiturates due to poor efficacy and potential toxicity or dependency 3, 4

Perimenstrual prophylaxis with long-acting NSAID (e.g., naproxen) or long-acting triptan (e.g., frovatriptan 2.5mg twice daily or naratriptan 1mg twice daily) can be effective for women with pure menstrual migraine 1, 2, 5
Continuous use of combined hormonal contraceptives can benefit women with pure menstrual migraine without aura, but are contraindicated in women with migraine with aura due to increased stroke risk 1, 2, 5
Standard preventive medications such as beta-blockers, candesartan, and topiramate can be used for women with frequent migraines throughout the month 1, 2

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

The American Academy of Family Physicians recommends NSAIDs as the initial treatment for mild-to-moderate menstrual migraine attacks, with options including ibuprofen 400-800mg every 6 hours and naproxen sodium 275-550mg every 2-6 hours 6, 7
The American Academy of Neurology suggests that triptans should be used when NSAIDs provide inadequate relief, with rizatriptan 10mg and sumatriptan 50-100mg being effective options 6
The American Family Physician recommends avoiding opioids and barbiturates due to dependency risk, rebound headaches, and poor efficacy 7

The American Family Physician suggests that transcutaneous estradiol 1.5mg daily (gel or patch) applied perimenstrually has grade B evidence for women with pure menstrual migraine 8, 9

The American Family Physician recommends beta-blockers (propranolol 120-240mg daily) as a daily preventive therapy option for migraines that occur frequently throughout the month 9

The American Academy of Neurology advises against using triptans during the aura phase, as they are ineffective and should only be used when the headache begins 6
The American Academy of Neurology recommends monitoring for medication overuse and limiting triptan use to educate patients on rebound headache risk 6