My Treatment: Headache - Menstrual Migraine

Preventive Treatment Strategies for Menstrual Migraine
By David M. Biondi, DO

Migraine is an episodic neurological disorder—episodic means a migraine attack can occur once a month, once a week or even once every day and neurological disorder means migraine occurs in the brain and nerves. Migraine attacks are associated with an activation of sensory nerves in the face, head, and neck causing pain; inflammation of blood vessels around the brain and in the scalp causing an increase in pain severity and usually throbbing; and then intense activation of certain brain pathways causing many different neurological symptoms. People who suffer from migraines typically experience intense headache, nausea, sensitivity to light and sound, numbness or tingling sensations, dizziness, difficulty thinking, and some level of disability during an attack. The age at which migraine occurs for the first time for boys peaks at about 10 years old while for girls the peak age for experiencing their first migraine is near 14 years old, with many beginning around the first menstrual period.

During childhood, more young boys have migraine than girls but this changes at puberty. After puberty, migraine eventually affects women three times more often than men. Hormones—especially estrogen—appear to have important effects on migraine activity. About 60% of women who have migraine experience attacks before or during their menstrual period, although only about 10% to 15% will have migraine only when they have their menstrual period. The majority of women will have migraine at other times of their cycle but will experience attacks of greater severity one to two days before or during their menstrual period. The timing of many menstrual-related migraine attacks can be predicted since the greatest vulnerability for attacks occurs between two days before and three days after the start of menstrual flow. This predictability allows women to use short-term preventive treatments that are aimed at stopping migraine attacks before they occur or reducing the intensity of headaches that might still occur.

Another time when women are more likely to have a migraine attack is around the middle of the menstrual cycle at the time of ovulation. Menstrual and ovulation-related headaches appear to occur when estrogen levels in the blood drop during the menstrual cycle. Estrogen is involved in setting the threshold for pain activity. Falling estrogen levels are associated with a greater sensitivity to pain and increased activity in body systems that cause inflammation. These changes can make women more susceptible to experiencing several different types of pain, such as headache, cramps, and muscle or joint aches, just before or during their menstrual period. Taking oral contraceptive pills (ie, birth control pills) can exaggerate the drop in estrogen levels before the start of menstrual bleeding. Consequently, taking the pill can sometimes worsen migraine patterns. Many women will experience an improvement in their migraine after menopause.

There are a number of medicinal and non-medicinal treatments for the prevention of menstrual migraine. These treatments often work best if combined.

Non-medicinal Treatments for Menstrual Migraine
Women with migraine are generally more susceptible to dietary, physical, environmental, and other triggers for migraine attacks during the week before and the first few days of their period. Following are some guidelines that can decrease the likelihood of having a migraine from these triggers.

1. Eat regularly scheduled, well-balanced meals. Avoid missing meals because low blood sugar and hunger are frequent triggers for migraine attacks. On the other hand, avoid eating sweets or meals the contain a lot of carbohydrates because doing so might lead to a rapid drop in blood sugar levels two to three hours after you have these foods (this is sometimes called a "sugar or carbohydrate crash").
2. Drink plenty of fluid. Avoid dehydration because this too is a frequent migraine trigger.
3. Get a good night's sleep. Follow a regular and consistent schedule of waking and sleeping. Avoid going to bed late, "sleeping in," becoming sleep deprived, or a haphazard sleep schedule.
4. Stay away from well-known migraine triggers such as wine, beer, or other alcohol containing drinks; chocolate and other sweets; aged cheeses such as cheddar or Brie; and salty foods, especially during the week before your period.
5. Participate in a regular aerobic exercise program. If you have not been exercising regularly, discuss exercise plans with your doctor or a personal trainer and set up a physical conditioning plan that matches your needs. Start your exercise program slowly and gradually build up your level of activity as your physical condition improves. This type of treatment works best if you continue the exercise program on a regular basis, not just on weekends or only once in a while.
6. Learn and regularly practice biofeedback and other relaxation techniques. These types of treatment have demonstrated excellent benefit in clinical studies; and best of all, there are no potential side effects.

Short-term Prevention of Menstrual Migraine
Short-term migraine prevention, often called "mini-prophylaxis," can be used to preemptively manage predictable migraine attacks such as those related with menstruation or ovulation. Your physician may prescribe a medication that you begin taking a day or two before the expected onset of headache and continue taking on a regular daily schedule for five to seven days. There are several medications that have been used for mini-prophylaxis of migraine.

1. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and naproxen, in "prescription strength" dosages have been used successfully for the prevention of menstrual migraine. Women with stomach ulcers or certain kidney problems usually cannot use these medications. Consult with your physician before taking any over-the-counter medication.
2. Migraine-specific drugs such as triptans or ergot derivatives also have been successful for short-term prevention of menstrual migraine. Women with certain heart or circulation problems might not be able to use these medications.

a. Ergot derivatives, such as ergotamine tartrate, dihydroergotamine, or methylergonovine, have all been used for mini-prophylaxis. Nausea and muscle cramps might occur in some women. Dihydroergotamine is available as a nasal spray while the other two are tablets.
b. A few triptans have been found effective for mini-prophylaxis of menstrual migraine in clinical drug studies. The medications that have been studied specifically for this purpose are frovatriptan, naratriptan, and sumatriptan. These medications generally are better tolerated than the ergot derivatives.

3. NSAIDs can be used together triptans or ergot derivatives in cases of menstrual headaches that do not respond to any of these medications alone. Triptans and ergot derivatives should not be used together or within 24 hours of one another. Non-medicinal treatments can certainly be added to any of these medications, and this often is a way to get the best results.

Long-term Prevention of Menstrual Migraine
Long-term prevention, which means taking preventive medication(s) every day of the month, might be required if migraine attacks occur too frequently (ie, averaging more than four headache days in a month), migraine attacks cause too much disability, or medications used for mini-prophylaxis are not effective, too expensive, or unsafe to use because of other medical conditions. There are many different kinds of medications prescribed for long-term migraine prevention. The medications most often used for migraine prevention are blood pressure lowering drugs such as beta-blockers or calcium channel blockers, antidepressants and antiepileptic drugs. Each medication in these classes of medication has its own benefits and side effects. Your physician will determine which medication is best for you. Sometimes you may need more than one medication to control particularly resistant headaches. It is not unusual to try several medications or combinations of medications before the best treatment is found. It might take several weeks for a medication to demonstrate its benefit.

Summary
Migraine is a common medical condition that affects many more women than men. Migraine attacks are more frequently experienced and are particularly severe before and during menstruation. Falling estrogen levels in the blood two to three days before the start of menstrual flow appears to have an important effect on worsening migraine activity. Menstrual-related migraine often is predictable, which may provide a good opportunity to use short-term migraine preventive treatments, called mini-prophylaxis. Non-medicinal treatments such as dietary and lifestyle adjustments have an important role in reducing the effect of potential migraine triggers, especially before or during menstruation when migraine attacks are more likely to occur. Sometimes preventive medications must be taken every day during the month when migraine attacks are frequent or are associated with a lot of disability. Many times it is best to use a combination of treatment strategies to achieve the most effective control for menstrual migraine.

David M. Biondi, DO, is director of the Headache Management Program for Spaulding Rehabilitation Hospital in Boston and headache management consultant for the Department of Neurology at Massachusetts General Hospital. He is an Instructor in Neurology at Harvard Medical School. Dr. Biondi serves on the credentials committee and examination council of the American Board of Pain Medicine, as educational director of the Boston Headache Symposium, on the board of the Headache Cooperative of New England, and is a member of the American Academy of Neurology, National Headache Foundation, American Headache Society, the American Pain Society, the American Academy of Pain Medicine, and the International Headache Society.

He is the 2004 recipient of the National Headache Foundation Lectureship Award. Dr. Biondi lectures extensively nationally and internationally and has authored or co-authored numerous articles for scientific journals. He received his degree in osteopathic medicine from the University of New England College of Osteopathic Medicine in Biddeford, Maine. Dr. Biondi is board certified in neurology and pain medicine.