Migraine is a common and debilitating disorder that affects millions of Americans. Though migraine occurs with the same frequency in boys and girls, the girls outnumber boys after puberty.  By adulthood, women are three times as likely to suffer from migraine as men.  This is probably because the hormonal fluctuations that occur in a woman’s menstrual cycle can trigger headaches.  Up to 60% of women with migraines report headaches around the time of menstruation.  Approximately 7-14% of women have migraines exclusively at this time of the month.  

Migraine can occur before, during, or after menstruation.  Menstrual migraine is defined as a headache attack that occurs two days before and up to three days after the onset of a woman's period.  The most common day on which menstrual migraine occurs is the first day of bleeding.  Menstrual migraine is thought to be triggered by changes in hormone levels that occur during the menstrual cycle.  The most likely cause is the fall in estrogen levels that takes place just before the beginning of menses.  However, the full mechanism is not yet fully understood.

The treatment of menstrual migraine requires special consideration.  Women should be aware that many of the drugs used in treating migraine are potentially dangerous in pregnancy.  Also, menstrual migraine is often more difficult to treat than non-menstrual migraine.  You may need to try several different treatment options before finding headache relief.

The first step in management is to establish the presence of menstrual migraine. If the pattern is not clear, your doctor will ask you to keep a headache diary for several months, in which you can record your headache days, menstrual flow, and any other triggers.  Once the connection is determined, treatment can be initiated.  If you only have migraines around menstruation, acute therapy may be sufficient.  Medications may include anti-nausea medications, non-steroidal anti-inflammatory drugs (naproxen, ibuprofen and others) and the triptans (such as Imitrex, Zomig, Frova, Amerge, Axert, Maxalt and Relpax), amongst others.  Magnesium injections, which can be done in the office, can abort a menstrual migraine acutely.

Women who don't respond to acute therapy or suffer from more than 3-4 headaches per month may require preventative treatment. This may be either in the form of short-term daily medication taken prior to the menstrual migraine or medication taken throughout the entire month.  Daily magnesium supplements, or a magnesium injection several days before the expected onset of menstruation, are usually very effective in preventing menstrual migraines.  Magnesium also has the added benefit of being safe in pregnancy.

If menstrual migraines persist despite the above measures, then hormonal therapy may be considered.  This type of treatment would be initiated and monitored in conjunction with your gynecologist.  It often involves continuous contraception with an oral contraceptive such as Seasonale which is taken for three months continuously or Lybrel, which prevents menstruation for a year.  In addition to medications, lifestyle changes can be helpful in menstrual migraine.  These include avoiding known triggers, keeping regular sleep hours, frequent aerobic exercise and eating at regular intervals.