Migraine attacks (episodes) are often triggered by periods. Treatment of each migraine attack is no different than usual. However, there are treatments (detailed below) that may prevent period-related migraine attacks from occurring.
What is migraine?
Migraine is a condition that causes intermittent headaches, often accompanied by other symptoms such as feeling sick (nausea) or being sick (vomiting). Migraine attacks are often (but not always) one-sided, and often (but not always) throbbing. Some people with migraine find that bright lights or loud noises bother them and that moving their head can make the headache worse. Migraines can stop you carrying on with your normal activities even when the pain is not severe. Between migraine attacks, the symptoms go completely.
How do periods affect migraine?
In most people who have migraine, most attacks (episodes) of migraine occur for no apparent reason. However, something may trigger migraine attacks in some people. Triggers can be all sorts of things - for example, foods, stress, wine, tiredness, lack of fluid in the body (dehydration), long-haul travel.
For some women, migraine attacks occur during or just before periods. The cause or trigger of the migraine is thought to be the fall in the level of oestrogen that occurs at this time in the cycle. Oestrogen is one of the chemicals (hormones) that control the menstrual cycle. The blood level of oestrogen falls just before a period. It is not a low level of oestrogen that is thought to be the trigger but the drop in the level of oestrogen from one level to another.
Menstrual migraine occurs when you have a migraine attack around most periods that starts at any time from two days before to three days after the first day of a period. There are two patterns:
- Pure menstrual migraine occurs when migraine attacks happen only around periods and not at other times. This occurs in about 1 in 7 women who have menstrual migraine.
- Menstrual-associated migraine occurs when migraine attacks happen around periods but also happen at other times too. About 6 in 10 women who have menstrual migraine have this type of pattern.
Symptoms of menstrual migraine usually improve if you become pregnant, because during pregnancy there is a constant high level of oestrogen. As you approach the menopause, menstrual migraine attacks may become more frequent because your level of oestrogen tends to go up and down at this time. Once past the menopause, you have a constant stable low level of oestrogen, and menstrual migraine attacks tend to reduce.
Women who take the combined oral contraceptive (COC) pill, the contraceptive patch (the patch) and the contraceptive vaginal ring (the ring) have a fall in oestrogen in the pill-free week between pill packets. This is when the period or withdrawal bleed occurs. This fall in oestrogen may also trigger a menstrual migraine.
How is menstrual migraine diagnosed?
Sometimes a period and a migraine attack (episode) occur at the same time by chance. Therefore, to make the diagnosis, a doctor may ask you to keep a migraine diary for three months or so. This helps to see the pattern of your migraine attacks and whether you have menstrual migraine.
What are the treatment options for each migraine attack?
The treatment options are the same as for any other migraine attack (episode). Options include: painkillers, anti-inflammatory painkillers, antisickness medicines and triptan medicines. See separate leaflet called Medicines to Treat Migraine Attacks.
What are the treatment options to prevent menstrual migraine?
Some women have severe menstrual migraine attacks (episodes), and some of those women find that treating each attack when it comes is not very satisfactory. In this situation, you may wish to consider a treatment that aims to prevent the migraine attacks. Migraine prevention treatments do not completely prevent all migraine attacks but they can make them less frequent and less severe. It may be useful to continue your migraine diary to compare before and after treatment.
These include mefenamic acid, naproxen, ibuprofen and diclofenac. These are painkillers which can be used to treat each migraine attack once it occurs. However, one option is to take a short course of one of these medicines for a few days each time you have a period, even if you don't have a migraine, in order to prevent an attack. You can start taking the tablets a few days prior to an expected period, or when the period starts, and take them until the last day of bleeding. (Anti-inflammatory painkillers are also used to treat period pain and heavy periods. Therefore, this may be a particularly good option if you also have painful or heavy periods.)
Some people cannot take anti-inflammatory painkillers - for example, people with a duodenal ulcer, and some people with asthma. Side-effects are uncommon if you take an anti-inflammatory painkiller for just a few days at a time, during each period. However, read the leaflet that comes with the tablets for a full list of possible cautions and side-effects.
Topping up your level of oestrogen just before and during a period can prevent menstrual migraine by preventing the sudden drop in oestrogen levels that trigger it. Oestrogen skin patches or gels are sometimes used. You put the patches or gel on your skin for seven days starting from three days before the expected first day of your period. The oestrogen is absorbed through the skin into the bloodstream. This is like having hormone replacement therapy (HRT) just for seven days each month. (Unlike long-term HRT you do not need an additional progestogen medicine with the oestrogen.) Note: oestrogen supplements are not licensed for the treatment of menstrual migraine. However, many doctors are happy to prescribe them 'off licence' for this condition.
Contraceptives as a treatment for menstrual migraine
Hormonal contraceptives are a useful option if menstrual migraine is a problem and you also need contraception. Options may include:
Progestogen-based contraceptives to prevent ovulation (if ovulation is prevented then your hormone cycle is altered and becomes more level, with no drop in the oestrogen level to trigger a migraine attack).
- These include desogestrel (a progestogen-only pill (POP) - Cerazette®), the contraceptive implant (Nexplanon®), or the contraceptive injection.
- Most women with migraine at any age can use progestogen-based contraceptives - even if they have migraine attacks with aura.
- The only time you would not be advised to use progestogen-based contraception is if you started to develop migraine attacks with aura only after starting to take one of these types of contraceptive.
Combined hormonal contraceptives (the COC pill, the contraceptive vaginal ring and the contraceptive patch) also prevent ovulation; however, during the pill-free week some women with menstrual migraine will still experience their headaches. Moreover, not all women with menstrual migraine can take these treatments.
- If you have or develop migraine attacks with aura, you should never use combined hormonal contraception again at all.
- If you have migraine attacks without aura you should not use combined hormonal contraception again if you are aged 35 or older. See separate leaflet called Migraine, which deals with migraine with aura.
In some women with migraine who use combined hormonal contraceptives, migraine attacks (episodes) are also triggered by the drop in the blood level of oestrogen during the pill-free or patch-free interval.
- So long as these migraine attacks are without aura AND you were already known to have migraine without aura before starting the pill or the patch, there is usually no need to stop your combined hormonal contraceptive unless you wish to try a different method.
- If they are migraines with aura you should stop using combined hormonal contraception.
- If you have never had migraines of any sort before, you should stop using combined hormonal contraception.
If you chose a combined hormonal contraceptive (pill, ring or patch) in the hope of reducing menstrual migraine but still have migraine attacks without aura in the pill-free week then options to consider to reduce migraine in the pill-free week are:
- Changing to a COC pill with less progestogen. Migraine attacks during the pill-free interval seem to occur less often in women who take a pill with a lower dose of progestogen.
- Tri-cycling your combined hormonal contraceptive. This means using your combined hormonal contraceptive continuously for three packets, rings or patches without any breaks, followed by a seven-day contraceptive-free interval. This keeps the level of oestrogen constant for nine weeks (three weeks each):
- By doing this you have fewer withdrawal bleeds and, therefore, fewer migraine attacks. It is OK to have only one withdrawal bleed every three packets. Note: you can only do this with pill types that have the same dose of progestogen for each dose. These are the commonly used types; however, check with your doctor or nurse if you are unsure.
- Using oestrogen supplements during the seven-day pill-free, ring-free or patch-free interval.
- A change to a different method of contraception.
Triptans are not licensed for prevention of migraine. However, some studies have shown that taking triptans regularly for a few days each month, starting just before the time in your cycle that your migraines occur, can prevent or reduce the frequency of menstrual migraines. This option is usually started in specialist headache clinics.
Further reading and references
; NICE Clinical Guideline (September 2012)
; NICE CKS, May 2016 (UK access only)
; Faculty of Sexual and Reproductive Healthcare, 2016
; Management of menstrual migraine: a review of current abortive and prophylactic therapies. Curr Pain Headache Rep. 2010 Oct14(5):376-84. doi: 10.1007/s11916-010-0138-2.
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