Menstrual migraine

Criteria

The International Classification of Headache Disorders (ICHD-3) describes two forms in its appendix, which holds criteria still under study:

• The window is day 1 ± 2, that is days −2 to +3. Day 1 is the first day of bleeding, day −1 is the day before. There is no day 0.
• Menstruation here includes withdrawal bleeding on combined oral contraceptives and cyclical hormone replacement therapy.
• Attacks must meet the criteria for migraine without aura. Menstrual attacks are mostly without aura.
• With aura. ICHD-3 also lists pure menstrual migraine with aura (A1.2.0.1) and menstrually related migraine with aura (A1.2.0.2). This page covers the criteria without aura.

Find your window

How common it is

Estimates differ by method:

• In a Norwegian population study of 10,176 women aged 30–44, based on self-report, 21% of women with migraine had menstrual migraine: 7.7% the pure form and 13.2% the menstrually related form (Vetvik 2010).
• In a 2023 review, menstrual migraine affected about 6% of women of reproductive age. Among women aged 30–34, 0.8% had the pure form and 5.3% the menstrually related form (Raffaelli 2023).
• The Migraine Trust states that up to two-thirds of women with migraine may have attacks linked to periods, and fewer than 1 in 100 have pure menstrual migraine.

ICHD-3 notes that many women over-report the link between attacks and menstruation. A prospective diary is more accurate than recall.

How the attacks differ

Compared with attacks at other times of the cycle, perimenstrual attacks are:

• longer, by up to 35% (Raffaelli 2023);
• more severe and with more associated symptoms (Ornello 2021);
• less responsive to acute medicine (Ornello 2021);
• more likely to return after a triptan (Raffaelli 2023).

Why it happens

ICHD-3 states there is some evidence that the attacks follow the fall in oestrogen before a period, and that other hormonal changes may also play a part. The Migraine Trust adds the rise in prostaglandins at the start of a period. A 2023 review called the evidence for oestrogen withdrawal limited and conflicting: the original studies were small, not randomised and not blinded (Raffaelli 2023).

How to document it

• NICE suspects menstrual-related migraine when attacks start between 2 days before and 3 days after the start of a period in at least 2 of 3 consecutive cycles, and recommends a diary for at least two cycles to diagnose it.
• ICHD-3 recommends a prospective diary over at least three cycles for research. It is not required for a clinical diagnosis.
• Record each period day and each attack on the same calendar. The printable diary has a period-day column for this.

Treatment options

Treatment is chosen with a doctor. Guidelines and reviews name these options:

• Acute treatment. NICE uses the standard acute treatment of migraine for menstrual-related migraine; for migraine in general it recommends a triptan combined with an NSAID or paracetamol. No acute medicine is designed specifically for menstrual migraine (Ornello 2021).
• Short-term prevention around the period. When attacks are predictable and do not respond to acute treatment, NICE lists frovatriptan or zolmitriptan taken on the days attacks are expected, and notes that this use is off-label. Reviews also describe naratriptan, naproxen and oestradiol gel; the strongest trial evidence is for frovatriptan and naratriptan (Ornello 2021).
• Hormonal options. The Migraine Trust lists combined hormonal contraception as an option for some women, but not for those with migraine with aura or other risk factors for stroke.

Triptan days taken for short-term prevention add to the triptan day count and can lead to medication overuse. Count your days.

Short-term prevention needs a predictable cycle. This is one more reason to know your window from a diary rather than from memory.