Menstrual migraine affects over 50% of women. [1] Of these women, most will experience migraine during menses but also at other times of the month. Migraine during menses tends to be more severe, harder to treat and often reoccur even despite medications. [7]

Unfortunately, many women have resigned to menstrual migraine because if there’s little you can do about your cycle then there is not much you can do about your migraine attacks. Right?

Wrong.

There a number of options to treat and prevent, yes, prevent menstrual migraine attacks. To understand how and why these treatments can help, it is important to understand what’s going on during the month.

How The Menstrual Cycle Causes Migraine Attacks

Women who have a tendency to get menstrual migraine are those who are sensitive to hormonal fluctuations experienced just prior to the onset of menstruation. Just before menstruation there is a natural drop in progesterone levels.

The two important females hormones involved are progesterone and estrogen.

Progesterone is a natural steroid hormone involved in the female menstrual cycle that stimulates the uterus to prepare for pregnancy. It is a naturally occurring hormone in the female body that helps a female function as normal.

Estrogens or oestrogens (American and British English spelling respectively), are a group of compounds which are important in the menstrual and reproductive cycles. They are also naturally occurring steroid hormones in women that promote the development and maintenance of female characteristics of the body.

It is important to note that estrogens are used as part of some oral contraceptives and in estrogen replacement therapy for some postmenopausal women.

Throughout the natural menstrual cycle the levels of these hormones fluctuate. During the cycle, the levels of progesterone and estrogens also change in relation to each other. See the image below for how these levels change throughout the cycle.

This occurs as part of being a healthy fertile woman.

Several research studies confirm that migraine is significantly more likely to occur in association with falling estrogen in the late luteal/early follicular phase of the menstrual cycle. [8] Researchers failed to find an abosolute level of estrogen associated with migraine in this phase which supports the theory that falling levels of estrogen are more important than an absolute level. [8,9]

Menstrual cycle

 

This estrogen withdrawal trigger is independent of several important factors [9]:

  1. It is independent of ovulation as it can trigger migraine during the hormone-free interval of combined hormonal contraceptives.
  2. It is independent of menstruation and progestin as migraine can be triggered in those who have had hysterectomies.

Interestingly no obvious relationship between progesterone and migraine was found. [8]

Is estrogen withdrawal the sole trigger for menstrual migraine? Researchers suggest no. Menstrual migraine is associated is menstrual cramps and painful periods, both of which respond to nonsteroidal anti-inflammatory drugs. This suggests the involvement of prostaglandins. Prostaglandins are hormones created at the site of injury or illness. They help control inflammation, blood flow and the formation of blood clots.

Prostaglandins levels have been shown to increase threefold during the luteal phase of the menstrual cycle with a further increase during the first 48 hours of menstruation. This mirrors the timing of an increased risk of a migraine attack. [9]

Timing Is Important

Across the menstrual cycle menses typically occurs from day 1 to day 5. This is where up to 40% of women reported a migraine attack. In the 3 days prior to day 1 the incidence of migraine can also rise from around 10% to 25%. [8]

Timing is important because it can impact how best to treat each case of menstrual migraine. Below are different hormonal states that may be causing your regular menstrual migraine.

  • If it occurs just prior to the onset of menstruation then it may be due to the natural drop in progesterone levels.
  • Headaches and migraine attacks can also occur at ovulation when estrogen and other hormones peak.
  • Or it may occur during menstruation itself when estrogen and progesterone are at their lowest.

Knowing when your menstrual migraine occurs will determine the best prevention strategy. A good way to determine when your migraines are occurring is by keeping a record of at least 3 cycles to track exactly when your migraine attacks occurred. Remember to note the precise day(s) of your cycle as closely as possible.

Once you have a clear understanding of which days in your menstrual cycle the migraine is occurring, then you are in a better position to begin treating it. A simple diary can help significantly.

Diagnosis & Characteristics

Menstruation increases the likelihood of migraine without aura, but not for migraine with aura. [9]

Most women with migraine associated with menstruation also have additional attacks with or without aura at other times of the cycle. [9] The diagnosis for this type of migraine is referred to as Menstrually Related Migraine.

Fewer than 10% of women report migraine exclusively with menstruation and at no other time in the month. The diagnosis for this minority of female patients is Pure Menstrual Migraine. [9]

In those who have Menstrually Related Migraine, attacks which occur during menses are likely to be more severe, disabling, last longer and be less responsive to medications compared to attacks at other times of the cycle. [9]

Interestingly migraine with aura appears to be unaffected by menopause whilst migraine without aura can be exacerbated by menopause. [9]

To diagnose menstrual migraine a history, examination and diary analysis is required. There should only be investigations or further tests required to rule out any other primary causes of migraine. Relying solely on memory is considered insufficient and a diary over at least 2 to 3 consecutive menstrual cycles is considered best practice. [9]

International Classification of Headache Disorders (ICHD) III

A1.1.1 Pure menstrual migraine without aura

A. Attacks, in a menstruating woman, fulfilling criteria for 1.1 Migraine without aura and criterion B below
B. Occurring exclusively on day 1 ± 2 (i.e. days −2 to + 3) of menstruation in at least two out of three menstrual cycles and at no other times of the cycle

A1.1.2 Menstrually related migraine without aura

A. Attacks, in a menstruating woman, fulfilling criteria for 1.1 Migraine without aura and criterion B below
B. Occurring on day 1 ± 2 (i.e. days −2 to + 3) of menstruation in at least two out of three menstrual cycles, and additionally at other times of the cycle

A1.2.0.1 Pure menstrual migraine with aura

A. Attacks, in a menstruating woman, fulfilling criteria for 1.2 Migraine with aura and criterion B below
B. Occurring exclusively on day 1 ± 2 (i.e. days −2 to + 3) of menstruation in at least two out of three menstrual cycles and at no other times of the cycle

A1.2.0.2 Menstrually related migraine with aura

A. Attacks, in a menstruating woman, fulfilling criteria for 1.2 Migraine with aura and criterion B below
B. Occurring on day 1 ± 2 (i.e. days −2 to + 3) of menstruation in at least two out of three menstrual cycles, and additionally at other times of the cycle

Menstrual Migraine Management

The most effective strategy to manage menstrual migraine depends on several factors [9]:

  1. How well acute treatments work for the patient
  2. Predictability and regularity of menstrual cycle
  3. Use of or need for contraception
  4. The presence of menstural disorders or perimenopausal symptoms

Acute Treatment

All treatments indicated for acute migraine can be used to treat menstrual migraine. [9] Most treatments have not been tested specifically for menstrual migraine attacks so the true efficacy of some of these treatments in menstrual attacks is unclear.

Table: Acute Treatment of Menstrual Attacks of Migraine [9]

If used only around the time of menses then the risk of developing medication overuse headaches is low. Due to the long duration of menstrual attacks, repeated relapse can be an issue and a need for prevention is may be required.

Prevention

Those who have frequent migraine throughout their cycle regardless of the relationship to menstruation are likely to benefit from prevention strategies.

If preventive treatment reduces the frequency and severity of nonmenstrual attacks but not menstrual attacks, then a “mini” perimenstrual preventive strategy is indicated.

Perimenstrual Prevention

The prefix “peri” refers to prevention around menstruation. These are short term treatments which target the time of increased risk during the cycle. This differs from standard preventive strategies which continue on an ongoing basis across the full cycle.

Important: For perimenstrual prevention the use of the treatment is different from the label so the drug will need to be prescribed off-label. Always seek medical advice and supervision if considering perimenstrual prevention.

The best evidence supports the use of Frovatriptan. This is given the highest level rating as “A” for its efficacy evidence. Frovatripan can be taken at 5 mg twice daily starting 2 days before day 1 of the cycle, then 2.5 mg for 5 days from day 1 of the cycle (total of 6 days). [7,9]

Naproxen has a “B” level rating but it still the next best option to try if Frovatriptan has negative side effects or is contraindicated for any reason. 500 mg of naproxen is taken daily for 14 to 7 days over the high-risk window during the cycle. This treatment can commence one week prior and continue until one week after day 1 of the cycle. [9]

Level B evidence also supports the consideration of naratriptan and zolmitriptan.[9] Naratriptan 1 mg, 2 times a day is taken for 6 days, starting 3 days before expected onset of menstrual migraine. Zolmitriptan 2.5 mg is taken 2-3 times a day for 7 days starting 2 days before expected onset. [9]

Estradiol gel, an estrogen supplement, has a “C” level rating but is also another option. 1.5 mg daily is used for 7 days. This treatment regime commences 5 days before onset of menstruation and continues until day 2. This strategy prevents the late luteal phase drop in estrogen that can trigger estrogen withdrawal migraine. Important note: women using should be menstruating regularly with natural progesterone following ovulation providing endometrial protection. [9]

Prevention (Prophylaxis)

Continuous hormonal options aim to suppress ovarian activity and maintain hormonal environment.

Contraceptives

For women who also need contraception, there are several contraceptive strategies that may also benefit migraine. For migraine with aura, combined hormonal contraceptives have additional benefits including a reduced risk of endometrial and ovarian cancer. [9] Estrogen withdrawal during the hormone-free interval can trigger migraine attacks but this can prevented using estrogen supplements. Estrogen supplements that may be considered include [9]:

  • 10 mcg of oral ethinyl estradiol
  • 0.9 mg oral conjugated equine estrogens
  • 100 mcg estradiol patches
  • 2 g estradiol gel

A simpler way to reduce the number of withdrawal bleeds and number of attacks may be to use an extended cycle of 84/7 regimes or to none through continuous combined hormonal contraceptive use. [9]

Continuous combined hormonal contraceptive use are well tolerated. Unscheduled bleeding is common in the early cycles of treatment but usually resolves over time. Typically by 10-12 months 80-100% of women experience no bleeding.

Little evidence is found examining progestogen-only contraceptive methods and migraine. Some evidence suggests that if menses is avoided consistently then that can benefit the migraine condition. [9]

Side Effects

Combined hormonal contraceptives are associated with an increase in stroke by twofold. This risk should not be a significant concern for patients with no other cardiovascular risk factors.  Patients should be screened for these risk factors before prescription.

Common cardiovascular risk factors:

  • High blood pressure
  • Obesity
  • Smoking
  • High Cholesterol
  • Diabetes
  • Family history of cardiovascular event
  • Migraine with aura
  • Poor diet
  • Lack of physical activity

For example, the prescence of migarine with aura is associated with a twofold increase in stroke. Therefore patients with migraine with aura are not advised to add further risk by taking combined hormonal contraceptives. [9]

Gonadotrophin-releasing hormone analogues

This treatment has been found useful in resistant menstrual migraine conditions for some patients. It causes a reversible ‘medical’ menopause resulting in the cessation of ovarian activity. Add back hormone replacement therapy is usually required to treat any unwanted side effects and preserve bone density. [9]

Surgery

A hysterectomy with or without the removal of one or both ovaries increases the risk of migraine. [9] Therefore surgery is not recommend for menstrual migraine.

If a hysterectomy is indicated for other gynecologic factors then the effect on migraine can be managed with the immediate use of continuous transdermal estrogen replacement therapy. [9]

Therefore to answer the question: Should you get a hysterectomy for menstrual migraine? The answer is a definitive no.

A hysterectomy purely for menstrual migraine is permanent, invasive and an expensive surgical operation that has been shown to make migraine worse. [9]

Why is it ineffective for menstrual migraine?

Menstrual migraine attacks are caused by a fall in hormones which is triggered by the ovaries. Whilst menstruation stops with a hysterectomy, it does not stop the ovaries from continuing to trigger monthly hormonal fluctuations.

There are other ways to non-surgically address the hormonal fluctuations caused by the ovaries. See hormonal treatments listed above.

Alternative Menstrual Migraine Treatments

There are many different approaches to help manage menstrual migraine some involve medicinal treatments and others do not. Often it may involve a combination.

Rest assure that it is possible to reduce and in some cases eliminate menstrual migraine. But it may involve some effort, knowledge and work with a specialist.

Common treatments for those with menstrual migraine include:

  • Dietary changes
  • Lifestyle factors
  • Hormonal balancing
  • Magnesium
  • Other natural therapies

If there is an imbalance of estrogen in relation to progesterone then a healthy diet is the first step (in fact it should be one of the first steps for all migraine patients). What we eat, plays a huge role in your overall health and wellbeing.

“Nothing else affects our health more than what we eat.”

— Alexander Mostovoy, H.D., D.H.M.S., B.C.C.T.

 

If you experience migraine attacks then you diet becomes especially important.

We hear all the time from the health community something like ‘eat a varied and well-balanced diet to help prevent disease’. But it’s been said so many times we can become numb to this important advice.

To complicate things, some otherwise healthy foods may also act as trigger foods. Finding out which foods trigger attacks can be difficult.

Prevent menstrual or hormonal migraine attacks with the help of this simple one-page checklist

Dietary Changes

Why Is Diet Important For Menstrual Migraine?

Estrogen levels require stricter regulation compared to other hormones in your body to ensure the natural rhythm runs smoothly (2). If this balance is slightly off for what your body requires, then you may have uncomfortable physical symptoms such as PMS, breast tenderness, headaches and, in susceptible women, migraine attacks.

Small variances above or below the normal regulated levels can have significant impacts on your health.

The liver metabolizes estrogen. A healthy liver will rapidly metabolize estrogen but if it is overloaded with medications, artificial substances, chemicals or harmful substances from food or drinks can affect the metabolization of estrogen.

Our diet is thought to be the biggest factor affecting our hormones through the exposure to certain chemicals in food products. Research suggests that diet can attribute up to 90% of all factors affecting your hormones (3).

“Compared to other hormones such as progesterone, estrogen levels need to be tightly regulated for the ‘choreography’ to run as smoothly as Mother Nature intended — even small excesses or deficiencies of estrogen can have huge effects on your well-being. A healthy liver metabolizes estrogen rapidly into the more benign of its metabolites. But when it’s bogged down with detoxing medications, environmental chemicals, and harmful substances from food or drink, it can over-metabolize estrogen into its less desirable forms, which can pose a real threat to your health if allowed to accumulate.”

— Marcy Holmes, NP, Certified Menopause Clinician

 

Certain food ingredients act like toxins which can disrupt your hormonal balance, so reducing or eliminating these help keep your hormones in balance. Examples of toxins you may commonly come across include:

  • MSG (monosodium glutamate) – found as a flavor enhancer in many processed foods.
  • Hydrolysed Vegetable Protein
  • Aspartame

Avoid or, if possible, eliminate

If in doubt about what food triggers your attacks, it may be worth considering some of the following:

Keeping a food diary is highly recommended. Be careful to include in your diary not just what you eat, but also record other factors which affect your migraine attacks to minimize misattribution of a migraine attack to a particular food or trigger. Uncovering what exactly caused the attack takes a little time and patience but the process gives you much more control over your condition. The results are often surprising.

Food allergy tests unfortunately do not test for specific migraine triggers. But they can be effective at showing what foods your body is reacting abnormally too. Eliminating foods which cause stress or overreactions in the body may improve your migraine frequency or severity.

A detoxification may help cleanse your system of the offending substances but there is little scientific evidence supporting the efficacy of a detoxification. It may simply be a psychological way to push the ‘restart’ button when beginning a new eating regime.

If you are serious, consulting a certified health care professional like a nutritionist or dietitian to assist you is a good idea. Elimination diets can be tricky and sometimes dangerous to do by yourself. There is a risk of malnutrition if you don’t know exactly what you’re doing.

To ensure your wellbeing seek qualified professional support. That way you will have the best chance of reducing your attacks without malnourishment or starvation.

Another simple dietary preventative includes getting enough hydration, especially during menses.

Lifestyle Factors

Lifestyle factors like sleep and exercise play a central role in migraine management and sustainable remission.

The right levels of sleep and exercise are VITAL.

Sleep is a restorative function for brain and body. And it is not just about getting enough sleep each night. It’s about how regular your sleep/wake cycle is. Are you going to bed and waking up at the same time each night? What about on weekends?

It’s also about the quality of sleep. The hours of sleep before midnight count more. 9 hours total sleep starting from 10pm is much better than 10 hours of sleep starting from 1am.

Are you waking up at the same time each morning?

Nobody is perfect, but the better you can get into a consistent routine of high quality sleep, the better for your condition.

Exercise promotes a healthy metabolism, hormonal balance, reduces stress, assists in sleep, stabilizes your mood and gives you an overall sense of well-being.

Just in case you needed another reason, the brain loves exercise. Exercise is a great preventative tool for many with migraine and the science is proving it. One study showed [5] that exercising using the indoor bike for a 20 min workout 3 times per week was as effective as one of the most popular migraine preventatives – topiramate.

For a few people exercise can trigger migraine attacks. If that’s the case, start slowly and build gradually. Give yourself a generous and slow warm-up before jumping into your exercise. Be sensible about it. Don’t start by trying to run 5 miles. Don’t exercise on days when your feeling vulnerable to a migraine attack.

If you exercise outside, wear a hat, keep hydrated and don’t let yourself get too hungry.

The evidence for daily exercise is building. Starting small can be a 5 min walk or a short, easy bike ride.

You will feel better for it. When you take care of the body, the body is more likely to take care of you.

Hormone Balancing

Addressing hormones without addressing underlying diet and lifestyle factors is like trying to clean the house by sweeping all the dirt under the rug. It’s a superficial approach.

Hormones do have a significant influence on bodily functions. 80% of pregnant women experience a remission of migraine during pregnancy according to studies. [6]

To assess hormone levels, blood, saliva and urine testing may be performed to establish a baseline and to identify any hormonal imbalances which may be contributing to migraines.

Thyroid testing is also important as hypothyroidism is more common in those with migraine.

Commonly the key trigger is the falling levels of estrogen which occurs naturally before menses. Estrogen can be topped up in several ways such as via skin patches or gel which is absorbed into the bloodstream. A patch can be applied for 7 days beginning 3 days prior to the first day of menses. Note: if you are trying to get pregnant you should speak to your physician before you explore hormonal treatments.

Another increasingly popular approach to deal with the drop of estrogen involves stabilizing hormones through the use of the low dose estrogen combination pill which has a constant dose (monophasic).

For others, problems appear to arise due to the estrogen dominance and progesterone deficiency. In these cases, bio-identical progesterone in the second half of the female cycle to balance the hormones has shown some success (4).

It is a good idea to consult with a healthcare professional who has experience with menstrual migraine and who understands female hormones. Look for a headache specialist, certified gynecologist or endocrinologist who has a track record with menstrual migraine.

Magnesium

Research suggests that magnesium supplementation for those with menstrual migraine can be beneficial. It has also found that low magnesium levels may be attributed to a lower migraine threshold. Lower migraine thresholds make you more vulnerable to attacks and require less stimulation and fewer triggers to lead to an attack.

400mg of magnesium every day can be used as a migraine preventative. Unfortunately there no simple tests for magnesium deficiency as it’s the intracellular level of magnesium that we need to improve. The best way to see if it works for you is to try it and ensure that you are absorbing it effectively.

If the migraine attacks are severe or also occur frequently outside of menses then a migraine preventative may be prescribed.

When considering preventative medicinal treatments it is best to discuss what options might be best for you with your doctor who has your full medical history. Read more about the different preventative treatments for migraine here >>

Other Natural Therapies

Whilst there is less clinical evidence behind the efficacy of natural and homeopathic therapies, they may have fewer side effects, be better tolerated and offer a natural alternative.

That said, if they don’t help, you’ve wasted your money.

Do your research before jumping into these kinds of treatments to decide if it’s appropriate. Discover 6 natural, complementary treatments with evidence for migraine.

If you don’t have a well-balanced diet then you may not be getting your required vitamins and minerals. Supplements in this scenario may be useful. Some that have been reported to help those with migraine include: Riboflavin, Feverfew, Butterbur, Vitamin B6, Magnesium, Ginger, Coenzyme Q10 (CoQ10) amongst others.

Ordering the cheapest option from Amazon is not your best option. Vitamins are still considered medication but have far less regulation and quality controls in place. Often it’s worth paying extra for a reputable brand to ensure quality and safety.

Many vitamins are contraindicated for pregnant woman or woman trying to get pregnant so speak to your pharmacist or doctor before ordering them.

Perimenopause

Perimenopause increases the risk of migraine and additional complications around irregular periods which can make perimenstrual prevention (discussed below) difficult. Perimenopausal symptoms may also warrant specific treatment often with hormonal replacement therapy. [9]

Oral estrogen can make migraine worse so nonoral routes are preferred and administered continuously to stabilize hormone levels. [9]

Endometrial protection with progestin is needed for many and continuous delivery again is better tolerated than cyclical administration. [9] Levonorgestrel intrauterine system is the only currently licenses continuous progestin treatment available to perimenopausal women.

If estrogen is not an approved option for any reason then paroxetine 7.5 mg at bedtime is the only nonhormonal therapy approved by the FDA for the treatment of perimenopausal symptoms. Gabapentin has grade “A” evidence to help with symptoms from perimenopause and there is currently inadequate or conflicting data to support or refute this treatment for migraine additionally (Grade “U”).

Summary

To summarise, if your migraine attacks occur at the same time each month:

  1. Keep a diary to inform you and your healthcare professional of exactly when the attacks begin during your cycle.
  2. Take into account how predictable and regular your cycle is.
  3. Evaluate the need for contraception
  4. Is there a presence of menstrual disorder or perimenopausal symptoms?
  5. Consider daily prevention or perimenstrual prevention
  6. Review your diet
  7. Get enough quality sleep, consistently
  8. Exercise regularly
  9. Stay adequately hydrated, especially during menses
  10. Try magnesium supplementation
  11. Balance your hormones
  12. Consider other natural alternatives or supplements known to help those with migraine.

Often, it is the things we consume or do unknowingly that exacerbate migraine. Identifying and modifying these factors with an improvement to your lifestyle and diet is where you can have the most dramatic and sustainable results.

Are you struggling with menstrual migraine? Let me know in the comments below.

Need something simple for your hormonal migraine attacks?

Prevent hormonal or menstrually related migraine attacks with the help of this simple one-page checklist. For a limited time, we are emailing a copy to every reader.

Article References
  1. MacGregor E.A., Brandes J., Eikermann A., Giammarco R. (2004) Impact of migraine on patients and their families: the migraine and zolmitriptan evaluation (MAZE) survey-phase III. Curr Med Res Opin 20: 1143–1150
  2. Holmes, M NP, http://www.womenshealthnetwork.com/womenshealth/menstrualmigraines.aspx Accessed Oct 2013.
  3. Fürst P (October 2006). “Dioxins, polychlorinated biphenyls and other organohalogen compounds in human milk. Levels, correlations, trends and exposure through breastfeeding”. Mol Nutr Food Res 50 (10): 922–33.
  4. Mostovoy, A. ‘Migraines – Helpful Solutions’ http://www.drmostovoy.com/Migraines.html. Accessed Oct 15, 2013
  5. Varkey, Emma, et al. “Exercise as migraine prophylaxis: a randomized study using relaxation and topiramate as controls.” Cephalalgia 31.14 (2011): 1428-1438.
  6. Somerville, Brian W. “The role of estradiol withdrawal in the etiology of menstrual migraine.” Neurology 22.4 (1972): 355-355.
  7. MacGregor, A. ‘Hormonal Influences In Migraine’. Presented at ANZHS Masterclass. 18 August 2018.
  8. MacGregor, E. A., et al. “Incidence of migraine relative to menstrual cycle phases of rising and falling estrogen.” Neurology 67.12 (2006): 2154-2158.
  9. MacGregor, E. Anne. “Migraine management during menstruation and menopause.” Continuum: Lifelong Learning in Neurology 21.4, Headache (2015): 990-1003.