Migraine in women

Menstruation (also known as the menstrual cycle or the period) is a common migraine trigger in women. Around 20–25% of women with migraine will experience menstrual migraine, which refers to migraine attacks that occur from within two days before the start of bleeding from a period to three days after the bleeding starts. Some women only have menstrual migraine (pure menstrual migraine) but most women also have migraine attacks at other times of the menstrual cycle. Contraception-related migraine can occur when taking the combined oral contraceptive pill during the seven-day hormone-free period (when taking the inactive or sugar pills).

Menstrual migraine attacks generally last longer and are more severe than non-menstrual attacks. Other symptoms such as nausea, vomiting, sensitivity to light, sound, smell and touch can be more common and more debilitating. They can also be more difficult to treat, with rebound headache often occurring because of the prolonged duration of the attack. This is when headache initially responds to treatment, but recurs as the treatment wears off.

The cause of menstrual migraine relates to the drop in the hormone estrogen at the time of the period, which may increase the sensitivity of the brain to pain responses. Studies suggest that this drop in estrogen could directly cause a migraine attack through effects on brain neurotransmitters or lower an individual’s threshold or susceptibility to an attack in the presence of other triggering factors such as disturbed sleep, alcohol or stress. It has also been reported that migraine attacks can be less frequent or severe around the time of ovulation. Fluctuating levels of prostaglandins may also be involved. Prostaglandins are hormone-like substances involved in pain, inflammation and contraction of the uterus, which is the cause of period pain or cramps.

The treatment of menstrual migraine is the same as for any other migraine attack (e.g. non-steroidal anti-inflammatories (NSAID), triptans and anti-nausea medication). However, there’s also the option of a ‘mini’ preventive treatment. This involves taking medication from 2-3 days before the period starts until the bleeding stops (or for 3 days after the bleeding starts), usually 5-7 days in total. 

Mini-prevention options include:

• NSAID (e.g. naproxen or mefenamic acid, which also inhibits prostaglandins)
• Estrogen supplements (e.g. a patch or gel), although estrogen isn’t recommended for anyone with a history or high risk of breast cancer and headaches may occur when treatment ends
• Magnesium, taken 15 days from the start of a period until the next period begins. This can be particularly useful for women with irregular periods

Long-acting triptans (e.g. frovatriptan or naratriptan) are commonly used for ‘mini-prevention’ overseas, but we don’t have these options in Aotearoa New Zealand. There is some concern that using triptans for mini-prevention may just delay the headache and care must be taken to avoid medication overuse headache, which can develop if taking triptans for more than 9 days a month for several months. Gepants that treat migraine attacks are may be effective and do not appear to cause medication overuse headache but these are also not available in Aotearoa New Zealand.

The usual migraine preventive medications can also be used when menstrual migraine and non-menstrual attacks are frequent and disabling. The CGRP monoclonal antibodies have been found to be safe and effective in treating menstrual migraine.

Some contraception methods can also help manage menstrual migraine. Taking the combined oral contraceptive pill continuously without taking the seven days of inactive pills, or reducing the number of inactive pill days, can suppress estrogen and thus avoid migraine triggered by a fall in estrogen. Depot progesterone injections may have a similar effect, if bleeding is suppressed. It’s worth noting that oral contraceptives can worsen headaches in some people, especially during the seven-day hormone-free break if it is not taken continuously.

Combined oral contraceptive pills should be avoided in women who have migraine with aura, due to a small increased risk of stroke. Progesterone-only contraception is safe to use in migraine with aura and may reduce the number or severity of attacks.

For some people, their menstrual migraine is so severe that they want to remove the source of the pain and bleeding and get a hysterectomy, which is an operation to remove the uterus. However, this is not advised as it can actually increase or worsen migraine.

Learn more

Women with migraine who are planning to get pregnant are advised to check in with their doctor to talk about migraine management. If taking a preventive medication, get this reviewed for whether and how this may need to be withdrawn.

Anti-seizure medications, particularly sodium valproate (Epilim) and topiramate (Topamax) shouldn’t be used in pregnancy as they can damage the foetus. There’s no information about the safety of CGRP monoclonal antibodies in pregnancy and it is recommended to stop taking these for five months before trying to become pregnant.

• Learn more about anti-seizure medications and migraine

During pregnancy, many women report an improvement in migraine symptoms, typically in the second and third trimester. Around 50% of women report an improvement by the end of the first trimester and 80% by the second trimester. This improvement is more likely in women with migraine without aura and possibly those who have a history of menstrual migraine. However, people who have migraine with aura are less likely to improve during pregnancy and rising estrogen levels can even precipitate migraine with aura in women who did not previously experience it. After the baby is born, most people find their migraine pattern reverts to how it was before the pregnancy, although breast-feeding may be protective.

Managing migraine attacks during pregnancy can be challenging. Medicines that are thought likely to be safe include paracetamol, metoclopramide, caffeine (not exceeding 200mg a day) and ondansetron.

Non-steroidal anti-inflammatories (NSAIDs) are not to be used in the third trimester and are only used in the first or second trimester if the risks and benefits have been carefully considered. Discuss the use of triptans with your doctor – there are varying opinions on this.

Occipital nerve blocks can be used in pregnancy. Neuromodulation devices haven’t been tested in pregnant people but are considered likely to be safe. It’s also important to prioritise all the other health behaviours that can help manage migraines – regular sleep, meals and exercise, and managing stress.

For more information about NSAIDs and pregnancy

• Non-steroidal anti-inflammatory drugs (NSAIDs): avoid use in pregnancy, Medsafe
• Migraine in Pregnancy, American Migraine Foundation

Most medications should be avoided while breastfeeding – talk to your doctor about this.

Menopause is the time in a woman’s life when periods have totally ceased and the ovaries no longer produce eggs. Officially, it’s when you’ve gone for 12 months without a period. Perimenopause is the time of transition before menopause when hormone levels (estrogen and progesterone) fluctuate and periods become irregular. During perimenopause and menopause, symptoms such as hot flushes, night sweats, sleep disturbances, mood swings, anxiety, brain fog and vaginal dryness can occur. Perimenopause often starts around age 45 but can begin earlier, or later.

Migraine often improves after menopause but may worsen during perimenopause. Both of these outcomes are more likely in people with menstrual migraines. It may take a couple of years after periods stop for migraine attacks to reduce, as it takes time for estrogen levels to settle.

Hormone replacement therapy (HRT) can be used to even out the estrogen fluctuations and treat the symptoms associated with perimenopause, and may help with migraine. For people with migraine, HRT should be with low dose transdermal estrogen patches (and progesterone, if the womb is intact), which deliver a steady level of estrogen. Patches can be used in migraine with aura, as the estrogen doses are lower than in the combined oral contraceptive pill.

Migraine attacks can persist in the menopause since not all attacks are due to hormonal fluctuations. The usual approaches to management apply but more care may be needed when using a preventive migraine medication. As we age, our kidneys and liver may become less efficient at processing medications, leading to a higher risk of side effects or interactions with other medications. Older people taking tricyclic antidepressants such as nortriptyline (Norpress) and amitriptyline (Amirol) may be at an increased risk of developing dementia.

More information

• Migraine, menopause and HRT, National Migraine Centre

• Westport Headache Institute – Sex difference in migraine
• National Migraine Centre – Migraine, menopause and HRT
• American Migraine Foundation – Migraine and women’s health: your questions answered
• American Migraine Foundation – Hormonal and menstrual migraine: symptoms and treatment
• Migraine Again – What should you know about menstrual migraine?
• Migraine and Headache Australia – Hormonal headaches and menstrual migraine
• The Migraine Trust – Menstrual migraine
• American Migraine Foundation – Menstrual migraine treatment and prevention
• National Migraine Centre – Menstrual migraine
• National Headache Foundation – Menstrual migraine