What are the other Names for this Condition? (Also known as/Synonyms)

• Menstrually-Related Migraine (MRM)
• Menstrual-type Migraine
• Pure Menstrual Migraine (PMM)

What is Menstrual Migraine? (Definition/Background Information)

• Migraine headache is a chronic neurological disorder and the most common form of headache affecting girls and women that is characterized by severe pounding and pain on one side of the head, which can last for several hours
• Menstrual Migraines are described as migraine attacks occurring in a menstruating woman, just before or during a period (menses). In a majority of cases, the migraine headaches are present without aura
• According to the International Classification of Headache Disorders, Menstrual Migraines are subclassified into the following three types:
  • Pure Menstrual Migraine (PMM): When migraine attacks are observed ‘only’ on 2 days prior to, and on the first 3 days of menstruation (totaling 5 days). This should be observed in a minimum of two menstrual cycles out of a total of three cycles
  • Menstrually-Related Migraine (MRM): When migraine attacks are observed on 2 days prior to, and on the first 3 days of menstruation; and, may take place at other times of the menstrual cycle too. This should be observed in a minimum of two menstrual cycles out of a total of three cycles
  • Non-Menstrual Migraine: When migraine attacks are observed during or (just) prior to menstruation but is unrelated to the onset and course of the menstrual cycle. In such cases, menstruation may serve as a trigger for migraine onset. Thus, non-menstrual migraines are generally treated and managed as regular migraines that are present with or without aura
• The cause of Menstrual Migraine is related to alteration or decline in the levels of the hormone estrogen (and progesterone, to some extent), and a release of the hormone-like substance called prostaglandin. Generally, the severity of the condition is dictated by the magnitude of the hormonal change. This condition may be adversely influenced by the use of birth-control pills by the menstruating woman
• It is important to note that there are other headache types in women that are linked to the hormone estrogen (exogenous estrogen intake). This may occur during various events, such as pregnancy, perimenopause, and menopause, and/or from hormone replacement therapy undertaken for menopause. Such headaches are collectively termed “estrogen-withdrawal headaches” and are associated with non-menstrual factors
• The difference between Pure Menstrual Migraine and Menstrually-Related Migraine is significant from the standpoint of treatment, since prophylactic hormonal therapy is reportedly more effective for the former condition than the latter
• In the context of menstruation, there are headaches that occur 7-14 days before the period starts, these are called period headaches or premenstrual headaches (or PMS headaches). Typically, these headaches form a part of the premenstrual syndrome (PMS) symptoms, which are observed in over 90% of the women during their reproductive years

Who gets Menstrual Migraine? (Age and Sex Distribution)

• Menstrual Migraine is observed in girls and women who are menstruating, typically between the years 12 and 50
• According to some reports, anywhere between 20% to 43% of the women are affected by Menstrual Migraines during their reproductive years
• Worldwide, girls and women of all racial and ethnic groups may be affected

What are the Risk Factors for Menstrual Migraine? (Predisposing Factors)

• Menstrual Migraines are associated with hormonal changes that occur in the body, just before and during menstruation
• The use of contraceptive pills can increase the risk for migraines. It can also aggravate migraines in some women, while decreasing severity in others
• Girls have a higher risk for Menstrual Migraines during their first year of period onset (following menarche)
• A family history of the condition may be a risk factor

It is important to note that having a risk factor does not mean that one will get the condition. A risk factor increases one’s chances of getting a condition compared to an individual without the risk factors. Some risk factors are more important than others.

Also, not having a risk factor does not mean that an individual will not get the condition. It is always important to discuss the effect of risk factors with your healthcare provider.

What are the Causes of Menstrual Migraine? (Etiology)

Women are three-times more prone to migraine headaches than men. This is reportedly due to the various events that occur in them, starting from puberty to menstruation, ovulation, pregnancy and childbirth, to menopause and post-menopause. The headaches that arise during these various phases are owing to hormonal changes and imbalances in the body and may be broadly termed hormonal headaches.

• Menstrual Migraines are believed to develop primarily from changes in the level of estrogen, and to a lesser extent from changed progesterone levels. According to research, a severe decrease in body estrogen levels are known to result in acute migraines
• These hormones have a role to play during the menstrual cycle; their levels are known to keep fluctuating throughout the cycle. Another contributory factor is reportedly the release of prostaglandin (lipid compounds) on the first two days of menstruation
• Fluctuating body hormone (estrogen) levels during the menstrual cycle affect certain neurotransmitters in the brain, such as serotonin, bringing about a change in their levels; lowered serotonin levels are known to constrict blood vessels in the brain causing headaches
• The use of birth-control pills may adversely affect the estrogen levels and make the condition even worse. There may be other non-hormonal triggers for Menstrual Migraines too
• The condition is normally observed two days prior to onset of the menstrual cycle and during the first three days of menstruation. The frequency of Menstrual Migraines is known to increase following puberty/menarche, until age 40 in women

What are the Signs and Symptoms of Menstrual Migraine?

The signs and symptoms of Menstrual Migraine are observed to be similar to a migraine headache without aura. Generally, migraines during a period can be more severe than those that occur at various other stages in a woman’s life. Nevertheless, it can considerably differ from one individual to another.

The signs and symptoms may be observed a few days before or during menstruation and may include:

• Changes in mood causing irritability and depression
• Changes in sensation such as altered taste and smell
• Large appetite or eating difficulties
• Cravings for alcohol or chocolates
• Fatigue and lethargy
• Joint pain
• Individuals may observe increased sensitivity to sound and light
• Increased or decreased urination frequency
• Moderate to severe headaches that can last for several hours and even for a few days
  • Pain on one side of the head; throbbing and severe pain
  • The pain gets worse with any physical activity
• Nausea and vomiting
• Difficulty in concentration
• Stomach upset

In some cases, women may present migraines with aura. The aura may be noted about 5 minutes to less than an hour before migraine onset and manifest as:

• Visual symptoms such as seeing various shapes, bright spots, flashes of light, or zig-zag patterns
• Vision loss or partial vision; double vision
• Pins and needles sensation in the arms or legs
• Hallucination
• Unsteadiness
• Anxiety

How is Menstrual Migraine Diagnosed?

The diagnosis of Menstrual Migraine may include:

• Complete physical examination and assessment of signs and symptoms
• Thorough analysis of personal and family medical history (including details of menstrual cycle and migraine headaches)
• Neurological examination by a qualified healthcare provider, if necessary
• Laboratory tests may be performed to rule out other causes for pain
• Computerized tomography (CT) scan of the head
• Magnetic resonance imaging (MRI) scan of the brain

In order to differentiate between a Menstrual Migraine and a non-menstrual migraine, it is important to maintain a headache diary for a period of minimum three months to record the migraine attack days and correlate them with the period days. This is important from both the diagnosis and treatment point of view.

Many clinical conditions may have similar signs and symptoms. Your healthcare provider may perform additional tests to rule out other clinical conditions to arrive at a definitive diagnosis.

What are the possible Complications of Menstrual Migraine?

The complications of Menstrual Migraine may include:

• In some, the condition may be frequent and disabling
• Emotional and mental stress; depression
• Poor performance at school or at work
• Recurrence of the condition
• Headaches due to medication overuse

Complications may occur with or without treatment, and in some cases, due to treatment also.

How is Menstrual Migraine Treated?

The treatment plan adopted for Menstrual Migraine may involve the following three steps:

• Acute treatment for migraine headaches:
  • Use of non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen
  • Triptans and ergotamines
  • Combination medication of acetaminophen, aspirin, and caffeine
  • Non-invasive vagus nerve stimulation
• Short-term prevention measures (or intermittent prophylaxis): Usually commenced 24-48 hours prior to expected migraine
  • Use of non-steroidal anti-inflammatory drugs (NSAIDs) such as naproxen sodium
  • Triptans and ergotamines (DHE) that may be in the form of nasal sprays or injections
  • Magnesium supplements
• Long-term prevention measures that may include:
  • Hormonal therapy that includes intake of estrogen supplements (in pill form or even as a skin patch)
  • Bringing about changes in the intake pattern of oral contraceptive pills; women with irregular period may be advised a suitable combination of contraceptive pills
  • Breaking/stopping the menstrual cycle for a period of time to aggressively treat the migraines; this may be recommended by some healthcare providers, if the migraines are continually severe
  • Antidepressants
  • Cardiovascular drugs
  • Anti-seizure drugs

Some of the non-traditional therapies that are used in treating migraine headaches include:

• Acupuncture
• Biofeedback (relaxation technique)
• Manual therapy involving massage and chiropractic treatments
• Use of vitamin and mineral supplements

Certain home care treatments may include:

• Muscle relaxation exercises including meditation, yoga, listening to music, and gardening
• Getting adequate sleep; while sleeping, resting in a dark quiet room
• Applying ice packs
• Limiting the intake of salt-based foods

How can Menstrual Migraine be Prevented?

Presently, it is not possible to prevent the onset of Menstrual Migraine. However, the following points may be considered towards managing the same:

• Keep a diary to record headache episodes on a regular basis; also record any other associated symptoms that may occur with the headaches
• Keep a diary to track period days (menstrual cycles)
• Keep track of any triggering factors including noting down all daily activities
• Avoiding such triggering factors that have been identified previously
• Reducing the effects of estrogen; regulating the use of contraceptive pills
• Having a stress-free routine with regular sleeping habits
• Regular exercise

Regular medical screening at periodic intervals with tests and physical examinations are recommended.

What is the Prognosis of Menstrual Migraine? (Outcomes/Resolutions)

• The prognosis of Menstrual Migraine is generally good with adequate treatment and support. The condition subsides in a vast majority of women following completion of the menstrual cycle
• In some women, the frequency and severity of the condition may be controlled/reduced through proper preventive medications

Additional and Relevant Useful Information for Menstrual Migraine:

The following DoveMed website link is a useful resource for additional information:

https://www.dovemed.com/health-topics/neurological-institute/