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Headache and medicine

Menstrual Migraines

Migraines¬†are different than common headaches. They typically cause high levels of throbbing pain and usually occur on one side of the head. Migraines are categorized as ‚Äúwith aura‚ÄĚ or ‚Äúwithout aura.‚ÄĚ If you have a migraine with aura, you may experience one or more of the following symptoms in the 30 minutes before your migraine:

  • unusual changes in smell
  • unusual changes in taste
  • unusual changes in touch
  • numbness in the hands
  • numbness in the face
  • tingling sensations in the hands
  • tingling sensations in the face
  • seeing flashes of light
  • seeing unusual lines
  • confusion
  • difficulty thinking

The symptoms of a migraine with aura can include:

  • nausea
  • vomiting
  • sensitivity to light
  • sensitivity to sound
  • in behind one eye
  • pain behind one ear
  • pain in one or both temples
  • a temporary loss of vision
  • seeing flashes of light
  • ¬†seeing spots

Menstrual migraine¬†is defined as migraine without aura that occurs in predictable association with menses. Whilst many women report that menstruation is a migraine trigger, there is a specific condition known as ‚Äėmenstrual migraine‚Äô. Its onset falls within a 5-day window, spanning 2 days before the onset of menses through the third day of bleeding.¬†

menstrual cycle

Although the complete exclusion of migraine with aura from diagnostic criteria is controversial, headache specialists generally agree that aura is uncommonly associated with MM, probably owing to the low-estrogen environment.

Women suffer migraines three times more frequently than men do; and, menstrual migraines affect 60 percent of these women. They occur before, during, or immediately after the period, or during ovulation.

Unfortunately, many women have resigned to menstrual migraine (also known as hormonal migraine) because they believe if there’s little you can do about your cycle then there is not much you can do about your migraine attacks. Right?

Wrong!

There are several options to treat and prevent, yes, prevent menstrual migraine attacks. To understand how and why these treatments can help, it is important to understand what happens and how things change during the month.

While it is not the only hormonal culprit, serotonin is the primary hormonal trigger in everyone’s headache. Some researchers believe that migraine is an inherited disorder that somehow affects the way serotonin is metabolized in the body.

But, for women, it is also the way the serotonin interacts with uniquely female hormones.

Menstrual migraine is usually associated with falling levels of estrogen or oestrogens (American and British English spelling respectively), the group of female sex hormones that specifically regulates the menstrual cycle fluctuations throughout the cycle and reproductive cycles. They are naturally occurring steroid hormones in women that promote the development and maintenance of female features of the body.

It is important to note that estrogens are used as part of some oral contraceptives and in estrogen replacement therapy for some postmenopausal women.

Throughout the natural menstrual cycle, the levels of these hormones fluctuate. During the cycle, the levels of progesterone and estrogens also change in relation to each other. See the image below for how these levels change throughout the cycle.

These fluctuations are normal and part of being a healthy and fertile woman.

Several research studies confirm that migraine is significantly more likely to occur in association with falling estrogen in the late luteal/early follicular phase of the menstrual cycle.

The withdrawal of estrogen is independent of several important factors:

1. It is independent of ovulation as it can trigger migraines during the hormone-free interval of combined hormonal contraceptives.

2. It is independent of menstruation and progestin as a migraine can be triggered in those who have had hysterectomies.

Menstrual migraine is also associated with Progesterone which is a natural steroid hormone involved in the female menstrual cycle that stimulates the uterus to prepare for pregnancy. It is a naturally occurring hormone in the female body that helps a healthy female function normally.

The two most accepted theories on the cause for menstrual migraine at the moment are:

1. the withdrawal of estrogen (ES-truh-jen) as part of the normal menstrual cycle and

2. the normal release of progesterone (pro-JES-tuh-rohn) during the first 48 hours of menstruation.

When the levels of estrogen and progesterone change, women will be more vulnerable to headaches. The degree to which those levels shift, not the change itself, determines how severe they are.

As early as 1966, researchers noticed that migraines may be worse for women who take birth control pills, especially ones with high doses of estrogen. Most work this way: You take pills that mix the two hormones for 3 weeks. For the week of your period, you might take placebo pills or no pill at all. That sudden drop in hormones can also lead to migraines. Talk to your doctor about pills with low amounts of estrogen or progesterone, since they cause fewer side effects.

The timing of a menstrual migraine attack provides clues on how best to treat each case. Below are different hormonal states that may be causing regular menstrual migraines.

1. If it occurs just before the onset of menstruation then it may be due to the natural drop in progesterone levels.

2. Headaches or migraines can also occur at ovulation when hormones peak.

3. Or it may occur during menstruation itself when estrogen and progesterone are at their lowest.

Knowing when your menstrual migraine occurs will determine the best prevention strategy. There are no tests available to confirm the diagnosis, so the only accurate way to tell if you have menstrual migraine is to keep a diary for at least three months recording both your migraine attacks and the days you menstruate. 

This will also help you identify non-hormonal triggers that you can try to avoid.

Causes

Scientist about migraine

·        Menstruation: Does it seem like you always get migraines right around your period? You’re not imagining that the two are linked. About 60% of women with migraine get a type of headache called menstrual migraines. Right before your period, the amount of estrogen and progesterone, the two female hormones, in your body drops. This drastic change can trigger throbbing headaches. Migraines may begin when young girls get their first period, but they can start at any time. They can continue throughout the reproductive years and into menopause.

·        Hormone replacement therapy: This type of medicine women take during menopause to control their hormones can also set off headaches. An estrogen patch is less likely to make headaches worse than other types of estrogen because it gives you a low, steady dose of the hormone.

·        Birth Control: The pill can make migraines worse for some women and lessen them for others. Three weeks out of every month, they keep the hormones in your body steady. When you take placebo pills or no pills at all, during the week of your period, your estrogen levels plummet and your head can pound. If you’re prone to hormonal migraines, taking birth control that contains low amounts of estrogen or only progestin may help.

·        Pregnancy: Hormone headaches during pregnancy are most common during the first trimester. During the first trimester, estrogen levels rise quickly, then level out. Because of this, many women notice that their migraines get better or go away after their third month of pregnancy. This is because blood volume increases and hormone levels rise. Women can also experience common headaches during pregnancy. These have many causes, including caffeine withdrawal, dehydration, and poor posture. If you still get headaches, don’t take any drugs. Many migraine medicines are bad for your baby. An over-the-counter pain reliever like acetaminophen should be safe but check with your doctor before you take it.

·        Perimenopause: In the years before menopause, estrogen levels go on a roller-coaster ride. Many women get both tension headaches, which result from stress, and migraines during this time. Dropping levels of female hormones cause migraines during perimenopause. On average, perimenopause starts four years before menopause, but it can begin as early as eight to 10 years before menopause.  

·        Menopause: Once you stop having periods for good, you’ll probably have fewer migraines. If you’re on estrogen replacement therapy and your headaches get worse, your doctor may lower the dose, advise you to stop taking it, or change to a different type. A hormone patch may be a better option if you and your doctor decide that estrogen replacement is right for you. It keeps your estrogen level steady, so a menstrual migraine is less likely to happen. Some women notice that while migraines get better, tension headaches get worse during this time.

What Else Causes Migraines?

Certain risk factors, such as age and family history, can play a role in whether you get migraines. Simply being a woman puts you at increased risk. Of course, you can’t control your gender, age, or family tree, but it may help to keep a migraine diary so that you can pinpoint which triggers activate your menstrual migraine attacks. The following can help you identify and avoid them:

  • poor sleeping habits
  • alcohol consumption
  • eating foods high in tyramine, such as smoked fish, cured or smoked meat and cheese, avocado, dried fruit, banana, aged food of any kind, or chocolate
  • drinking excessive amounts of caffeinated beverages
  • exposure to extreme weather conditions or fluctuations
  • stress
  • fatigue
  • exposure to extreme, intense levels of light or sound
  • breathing in strong odors from pollution, cleaning products, perfume, car exhaust, and chemicals
  • ingesting artificial sweeteners
  • consuming chemical additives, such as monosodium glutamate (MSG)
  • fasting
  • missing meals

Symptoms

The menstrual migraine¬īs symptoms are similar to migraine without aura. It begins as a one-sided, throbbing headache accompanied by nausea, vomiting, or sensitivity to bright lights and sounds. An aura may precede the menstrual migraine.

Menstrual migraine is much like a regular migraine. You’ll notice:

  • Nausea
  • Throbbing pain on one side of your head
  • Vomiting
  • Aura before the headache (not everyone gets this)
  • Sensitivity to light and sound

A PMS headache that comes before your period might have a few different symptoms:

  • Peeing less
  • Head pain
  • Joint pain¬†
  • Constipation
  • Acne
  • Bigger appetite
  • Fatigue
  • Lack of coordination
  • Cravings for chocolate, salt, or alcohol

Diagnosis 

Woman with headache

Menstruation increases the likelihood of migraine without aura, but not for migraine with aura. Most women with migraine associated with menstruation also have additional attacks with or without aura at other times of the cycle. The diagnosis for this type of migraine is referred to as Menstrually-Related Migraine.

Fewer than 10% of women report migraine exclusively with menstruation and at no other time in the month. The formal diagnosis for this minority of female patients is Pure Menstrual Migraines. 

In those who have Menstrually-Related Migraine, attacks that occur during menses are likely to be more severe, disabling, last longer, and be less responsive to medications compared to attacks at other times of the cycle. 

Interestingly, migraine with aura appears to be unaffected by menopause whilst migraine without aura can be exacerbated by menopause.

A formal diagnosis of migraine requires that at least two of four signature characteristics plus at least one of two associated symptoms be present. The four characteristics are:

  • moderate or severe pain
  • throbbing
  • unilateral location
  • intensification of headache upon the activity

Any combination of two suffices for diagnosis‚ÄĒmuch to the astonishment of many patients who mistakenly believe that migraine must be severe or one-sided.

Associated symptoms include either nausea or both photophobia and phonophobia, the latter often signified by the simple preference to be in a dark, quiet room during an attack.

Untreated, migraine usually lasts between 4 and 72 hours.

A practical, clinical approach to diagnosis is to look for the episodic disabling headache. By disabling, I mean the presence of associated nausea or the need to stop one’s activities and lie down. Stable history of attacks with predictable menstrual association offers further confirmation.

Your doctor might also do a physical exam and ask about your family history to help them determine any potential underlying conditions. If your doctor suspects something other than hormone fluctuation is causing your migraine, they may recommend additional tests, such as:

  • a blood test
  • a CT scan
  • an MRI scan
  • a lumbar puncture, or spinal tap

Treatment

Home Remedies and Alternative Treatments

To treat menstrual migraine, talk to your doctor about the options below, especially supplements, which can affect the way other medications work:

Riboflavin: Also known as B2, this vitamin may help prevent migraines. It could also turn your pee an intense yellow.

  • Ice:¬†Hold a cold cloth or an ice pack to the painful area on your head or neck. Wrap the ice pack in a towel to protect your skin.
  • Butterbur:¬†This herb can lower the number of migraines you have and make the headaches less severe. Supplements can help, but they might cause belching and other mild tummy troubles.¬†
  • Coenzyme Q10:¬†This antioxidant, available as a supplement, may help prevent headaches.
  • Acupuncture: This ancient Chinese practice that involves inserting needles along energy points in your body may lower the number of tension headaches you get and could prevent migraines.
  • Limit salt:¬†Eating too many salty foods could also lead to headaches. It‚Äôs wise to limit the amount of salt you eat around the time of your period.
  • Relaxation techniques:¬†These include progressive muscle relaxation, guided imagery, and breathing exercises. They can‚Äôt hurt, and some experts say they help with headaches, but there isn‚Äôt a lot of solid proof.
  • Massage:¬†There‚Äôs some evidence that shows it can help ease migraines, but again, doctors aren‚Äôt exactly sure how it works.
  • Exercise:¬†Regular exercise may help relieve migraines triggered by hormones. Other women may find that exercising makes their headaches worse. Stay hydrated, eat a high-protein meal before exercising, and warm up your muscles before exercise to maximize the migraine-busting benefits.
  • Biofeedback:¬†Biofeedback may improve your headaches by helping you monitor how your body responds to stress. It may help with both tension headaches and migraines, but doctors aren‚Äôt exactly sure why.
  • Reducing Stress:¬†Lowering stress and anxiety may sound easier said than done, but there are simple steps you can incorporate into your daily life. Try a few minutes of meditation or yoga after waking up in the morning or before going to bed. Practice deep breathing exercises during difficult situations.
  • Magnesium:¬†Low levels of this mineral can lead to headaches. Supplements may help. But they can give you diarrhea.
  • Feverfew: This herb can prevent migraines, but supplements can cause aches, pains, and mouth sores.

Check with your doctor before using any supplements as they are not regulated like prescription medicines they may contain substances that are not safe.

Medical Treatment

Migraines occurring just before and during menses can be the most challenging kind to treat and frequently do not respond to the same medicines that work the rest of the month.

Your doctor may recommend that you try an over-the-counter (OTC) pain medication, such as naproxen sodium (Aleve) or ibuprofen (Advil, Midol, Motrin IB, others). They may advise you to take these on a scheduled basis, before the onset of pain. If your sodium levels are found to be high during your physical exam, your doctor may also recommend that you take a diuretic.

However, there are several treatment options depending on the regularity of your menstrual cycle, whether or not you have painful or heavy periods, menopausal symptoms or you also need contraception. Although none of these options are licensed specifically for menstrual migraine, they can be prescribed for this condition if your doctor feels they would benefit you.

If you have a migraine and heavy periods, taking an anti-inflammatory painkiller such as mefenamic acid could help. Mefenamic acid is an effective migraine preventive and is also considered to help reduce migraines associated with heavy and/or painful periods. A dose of 500 mg can be taken three to four times daily. It can be started 2 to 3 days before the expected start of your period. If your periods are not regular, it is often effective when started on the first day. It is usually only needed for the first two to three days of your period. Naproxen can also be effective in doses of around 500 mg once or twice daily around the time of menstruation.

You may wish to discuss using estrogen supplements with your doctor. Topping up your naturally falling estrogen levels just before and during your period might help if your migraine occurs regularly before your period. Estrogen can be taken in several forms such as skin patches or gel. You put the patch on your skin for 7 days starting from 3 days before the expected first day of your period. Similarly, you rub the gel onto your skin for 7 days. In this way, the estrogen from the patch or gel is absorbed directly into your bloodstream. You should not use these supplements if you think you are pregnant or you are trying to get pregnant. Again keeping a diary of your migraines will help you to judge when best to start the treatment. 

If your periods are irregular your doctor may suggest other ways to try and maintain your estrogen levels at a more stable rate such as a combined oral contraceptive pill.

Many different prescription drugs are available to help relieve migraine pain. These can include:

  • beta-blockers
  • ergotamine drugs
  • anticonvulsants
  • calcium channel blockers
  • onabotulinumtoxinA (Botox)
  • triptans
  • CGRP antagonists to prevent migraines

If you’re on hormonal birth control, your doctor may also recommend that you switch to a method with a different hormone dose. If you aren’t on hormonal birth control, your doctor may recommend that you try a method such as a pill to help regulate your hormone levels.

Hormonal

Estrogen supplementation with a pill, vaginal gel, or estrogen patch can be used during the menstrual week to prevent the natural hormonal drop that sets off menstrual migraines. This approach is easier in those with predictable menstrual cycles. Often, this is most convenient if you are already taking a birth control pill or the inserted vaginal ring for contraception. During the week in which there is no active pill, or the vaginal ring is removed, an estrogen gel of 1.5 mg per day, or an applied moderate-to-high-dose estrogen patch, will decrease or prevent menstrual migraine.

Triptans or Ditans

Your doctor may prescribe triptans or ditans, these are medications that block pain signals in your brain. They often relieve pain from your headache within two hours and help control vomiting. If your period comes every month like clockwork, you can start these drugs a few days before your bleeding starts and continue for up to a week. 

This often prevents the migraine from coming on. If your period doesn’t always stick to a schedule, your doctor may suggest you try a different type of drug that will prevent a headache from happening in the first place.

Multiple studies have been done with the acute medications typically used to treat usual migraines, but dosed continuously in the menstrual window, twice a day. This approach appears to decrease or eliminate menstrual migraines, although there are concerns that the migraines may be worse or become more frequent at other times of the month, possibly related to rebound or medication overuse. This would particularly be problematic in women who have frequent migraines throughout the month, as well as menstrual migraines.

The American Headache Society Evidence-based Guidelines rated frovatriptan as effective (Class A), and naratriptan and zolmitriptan as probably effective (Class B) for use in mini-prevention. However, the FDA did not feel the evidence of benefit for frovatriptan was sufficiently strong to approve it for this indication and has not given any triptan a recommended indication for mini-prevention.

Triptan dosing for mini-prevention is generally given twice daily. Either naratriptan 1 mg or zolmitriptan 2.5 mg dosed twice a day or frovatriptan given with a starting dose of 10 mg, then 2.5 mg twice a day is a typical regiment in the menstrual window that have studies backing their effective use.

Triptans are administered in various forms like;

  • Oral Tablet

A fast-acting triptan such as sumatriptan, rizatriptan, zolmitriptan, almotriptan, or eletriptan, taken early in the migraine, and coupled with a non-steroidal anti-inflammatory drug (NSAID) such as naproxen or ibuprofen taken at the same time may be sufficient. A branded combination formulation sumatriptan-naproxen with a fast onset of action is TREXIMET (GlaxoSmithKline, Philadelphia, PA, USA). A dissolvable powder put in water of prescription diclofenac approved by the Food and Drug Administration (FDA) for migraine, brand name CAMBIA (Nautilus Neurosciences, Inc., Bedminster, NJ, USA), is also a faster form of NSAID.

  • Injectable

Sumatriptan is the only injectable triptan, and it comes in both needle and needle-free syringes. It is very fast, often giving benefit in less than 10 minutes, and can be used effectively even in the setting of vomiting or extreme nausea. In the throes of a bad migraine, absorption of pills can be very slow; injections bypass the digestive tract. Dihydroergotamine (DHE) is also a reasonable injectable medication that can be used, but it is not available with an auto-injector.

Injectable sumatriptan or DHE can be coupled with an NSAID for even more benefit.

  • Nasal

A nasal triptan such as zolmitriptan is also faster than a tablet, avoids the problem of vomiting and losing a pill, and can be more comfortable for those who prefer to avoid the pain of injection. DHE is available as a nasal spray (brand name MIGRANAL and generic, Zogenix, San Diego, CA, USA/Valeant, Bridgewater, NJ, USA), but must be given in 4 sprays over 15 minutes, which is often too slow for a situation with severe nausea or vomiting. Finally, there is also a nasal form of the NSAID ketorolac, brand name SPRIX (Luitpold Pharmaceuticals, Shirley, NY, USA), FDA-approved for moderate-to-severe pain but not specifically for migraine, and this can be used if triptans are not an option because of vascular disease or if they are ineffective.

Noninvasive Nerve Stimulation (nVNS) Therapy

These handheld devices are worn on your forehead, neck, or arm and allow the patient to self-administer a mild electrical pulse to the vagus nerve and bring relief from migraine pain.

Other Prescription Pain Medications

Sometimes your doctor may suggest other prescription pain medications, such as dihydroergotamine (D.H.E. 45). These cannot be taken in combination with triptans.

Can You Prevent These Headaches?

Migraine at work

If you have several debilitating headaches a month, your doctor may recommend preventive treatment with NSAIDs or triptans.

If your menstrual cycle is regular, it may be most effective to take preventive headache medication starting a few days before your period and continuing through up to two weeks after the start of your period.

If you have migraines throughout your menstrual cycle or you have irregular periods, your doctor may recommend that you take preventive medications every day.

Daily medications may include beta-blockers, anticonvulsants, calcium channel blockers, antidepressants or magnesium supplements. Your doctor might also consider monthly injections of a calcitonin gene-related peptide (CGRP) monoclonal antibody to help prevent your headaches, especially if other medications aren't effective.

Doctors will likely review any other medical conditions you may have to determine which medications may be most appropriate for you.

Making lifestyle changes, such as reducing stress, not skipping meals, and exercising regularly, also may help reduce the frequency, length, and severity of migraines.

There are a few other methods your doctor might suggest.

Hormonal: 

Estrogen supplementation with a pill, vaginal gel, or a patch can be used during the menstrual week to prevent the natural estrogen drop that sets off menstrual migraines. This approach is easier in those with predictable menstrual cycles. Often, this is most convenient if you are already taking a birth control pill or the inserted vaginal ring for contraception. During the week in which there is no active pill or the vaginal ring is removed, estrogen dosed at 1 mg per day, an estrogen gel of 1.5 mg per day, or an applied moderate-to-high-dose estrogen patch, will decrease or prevent menstrual migraine.

Birth control pills or patches and vaginal rings may help lower the number of menstrual migraines you have or make them less severe. But they don’t work for everyone. In some cases, they could make your migraines worse.

Your doctor might tell you to stay on birth control for 3 to 6 months without taking any placebo pills. This will prevent you from having a period and may stop your headaches. Dosing birth control pills continuously without a break for menses can be an effective way to reduce menstrual migraines. A hormonal approach can also be used with the vaginal ring so that at the time the ring is removed a new one is inserted immediately instead of waiting for the end of the menstrual week. Typically, a break is given for a menstrual period every 3-6 months during which aggressive treatment of the menstrual migraine may be implemented or mini-prevention used.

If you get migraines with auras, using birth control that contains estrogen and progesterone isn’t a safe option. Taking it could make you more likely to have a stroke. Other reasons your doctor may not want you to take birth control for your menstrual migraines include:

  • A history of smoking
  • High blood pressure
  • Obesity
  • Diabetes

For some, hormonal contraception may help reduce the frequency and severity of menstrual-related migraines by minimizing the drop in estrogen associated with the menstrual cycle.

Using hormonal contraception to prevent menstrual-related migraines may be appropriate for women who haven't been helped by other methods.

Other women may first experience migraines while using hormonal contraception. If you experience migraines while using hormonal contraception, talk to your doctor.

Tips for using hormonal contraception:

· Use a monthly birth control pill pack with fewer inactive (placebo) days.

· Eliminate the placebo days from most months by taking extended-cycle estrogen-progestin birth control pills (Camrese, Seasonique, others).

· Use birth control pills that have a lower dose of estrogen to reduce the drop in estrogen during the placebo days.

· Take NSAIDs and triptans during the placebo days.

· Take a low dose of estrogen pills or wear a patch during the placebo days.

· Use an estrogen-containing skin patch during the placebo days if you're using a birth control patch.

· Take the minipill if you're not able to take estrogen-progestin birth control pills. The minipill is a progestin-only birth control pill (Camila, Ortho Micronor, others) that's an alternative to oral estrogen-progestin birth control pills if you're not able to take estrogen-progestin birth control pills due to other conditions.

Medicines that treat migraines:

The drugs used most often to treat menstrual migraines can also help prevent them. These include NSAIDs and triptans or ditans, such as:

  • Eletriptan (Relpax)
  • Frovatriptan (Frova)
  • Lasmiditan (Reyvow)
  • Naratriptan (Amerge)
  • Rizatriptan (Maxalt)
  • Sumatriptan (Imitrex, Onzetra Xsail, Sumavel, Zembrace)
  • Sumatriptan/naproxen sodium (Treximet)
  • Zolmitriptan (Zomig)

Medicines that prevent migraines: 

If you don’t respond to other treatments and you have 4 or more migraine days a month, your doctor may suggest preventive medicines. You can take these regularly to make the headaches less severe or less frequent. These could include:

  • Seizure medicines
  • Blood pressure medicines and some antidepressants
  • CGRP inhibitors

Devices: 

These Four devices may bring relief.

  • Cefaly:¬†This small headband device sends electrical pulses through your forehead to stimulate a nerve linked with migraines.
  • ¬†SpringTMS or eNeura sTMS:¬†You place this magnet on the back of your head, and a split-second pulse interrupts abnormal electrical activity that could lead to a migraine.
  • ¬†gammaCore:¬†¬†This handheld device is placed over the vagus nerve in the neck and releases a mild electrical stimulation to the nerve's fibers to relieve pain.
  • Nerivio:¬†operated through an app on your smartphone, this device is worn on a band on your upper arm and sends low-frequency electrical pulses for 30 to 45 minutes to stop the onset of migraine headache.

NSAIDs:

Your doctor may recommend that you take nonsteroidal anti-inflammatory drugs (NSAIDs), NSAIDs taken twice a day during the 5-7 days surrounding the menstrual window may decrease or eliminate the menstrual migraine. Should the migraine occur during this time, it is likely to be less severe and becomes more amenable to treatment by a triptan. Naproxen 550 mg dosed twice a day as mini-prevention was shown to be effective when studied, and the benefit is believed to be a class effect, meaning that other NSAIDs are likely to give similar results.

Some women may take a combination of NSAIDs and triptans to relieve pain from menstrual migraines.

During Pregnancy

Estrogen levels rise rapidly in early pregnancy and remain high throughout pregnancy. Migraines often improve or even disappear during pregnancy. However, tension headaches usually won't improve, as they aren't affected by hormone changes.

Hormone-driven migraines often go away while you're pregnant. You might still get headaches during your first trimester, but they usually stop after that.

Avoid taking any medicine for your migraines during pregnancy. You might try a mild pain reliever, like acetaminophen, but check with your doctor to make sure it's safe for you before you take it. 

If you experience chronic headaches, ask your doctor about medications and therapies that can help you during pregnancy before you become pregnant. In fact, many headache medications may have harmful or unknown effects on a developing baby.

After delivery, an abrupt decrease in estrogen levels ‚ÄĒ along with stress, irregular eating habits, and lack of sleep ‚ÄĒ may trigger headaches again.

Although you'll need to be cautious about which headache medications you take while you're breastfeeding, you'll likely have more options than you did during pregnancy. Your doctor can tell you which medications you may take while you're breast-feeding.

Menopausal Migraine

For many women who have had hormone-related headaches, migraines may become more frequent and severe during perimenopause ‚ÄĒ the years leading up to menopause ‚ÄĒ because hormone levels rise and fall unevenly.

For some women, migraines get better once their periods have finally stopped, but tension headaches often get worse. If your headaches persist after menopause, you likely can continue to take your medications and use other therapies.

Hormone replacement therapy, which is sometimes used to treat perimenopause and menopause, may worsen headaches in some women, improve headaches in others, or cause no changes. If you're taking hormone replacement therapy, your doctor may recommend an estrogen skin patch. The patch provides a low, steady supply of estrogen, which is least likely to aggravate headaches.

If you're on estrogen replacement therapy and your migraines get worse, your doctor may lower the dose, prescribe it in a different form, or tell you to stop it altogether.

An estrogen patch can keep levels of the hormone steadier, so you're less likely to have bad migraines.

Will having a hysterectomy help menstrual migraine?

In order to answer this question, it’s important to understand the female reproductive organs, i.e. the uterus (womb) and the two ovaries each side of the uterus. The ovaries contain the eggs and also produce the sex hormones estrogen and progesterone.

At the beginning of each menstrual cycle, some of the eggs will start to mature under the influence of hormones produced by the ovaries. In the middle of the cycle, one egg (sometimes more) will ovulate. If the egg is not fertilized it will get absorbed by the body but more importantly, the level of hormones falls.

This fall of hormones triggers the lining of the womb to break down and be shed through the vagina ‚Äď called menstruation.

It is this withdrawal of hormones that acts as a trigger in women with menstrual migraine or menstrual-related migraine. So, if someone is considering a hysterectomy to treat menstrual migraines, it would not help as the ovaries would need to be removed.

There are a few diagnoses where for a small minority of women, surgical removal of the ovaries is the only measure that will allow them to continue a normal life. It is a very controversial treatment and is therefore very rare.

The first options are non-surgical ways of putting the ovaries out of action. Once the ovaries are out of action (in whatever way) the woman must take hormone replacement therapy until the average age of menopause (age 55) to prevent the long term consequences of estrogen deficiency (e.g. risk of osteoporosis).

One way to suppress the hormonal cycle is to use different forms of hormonal contraception. The combined contraceptive pill, one progestogen-only pill, the progestogen-only injection, and an implant will work by stopping ovulation.

You are Unique

Some women are more sensitive to the effects of hormones. If headaches are disrupting your daily activities, work, or personal life, ask your doctor for help. There are plenty of natural migraine remedies you can try to help alleviate your menstrual migraines.

In a nutshell, if your migraine attacks occur at the same time each month:

1. Keep a diary to inform you and your healthcare professional of exactly when the attacks begin during your cycle. Keeping a diary of your headaches, and recording when they occur concerning the menstrual cycle, as well as their severity and response to usual treatment, will help to determine the presence or absence of menstrual migraine.

2. Take into account the predictability and regularity of your cycle

3. Evaluate the need for contraception

4. Is there a presence of a menstrual disorder or perimenopausal symptoms?

5. Consider daily prevention or perimenstrual prevention

6. Review your diet

7. Get enough quality sleep, consistently

8. Exercise regularly

9. Stay adequately hydrated, especially during menses

10. Try magnesium supplementation

11. Balance your hormones

12. Consider other natural alternatives or supplements known to help those with migraines.

Often, it is the things we consume or do unknowingly that exacerbate migraines. Identifying and modifying these factors with an improvement to your lifestyle and diet is where you can have the most dramatic and sustainable results.

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