Menstrual migraine is defined as migraine without aura that occurs in predictable association with menses. Its onset falls within a 5-day window, spanning 2 days before the onset of menses through the third day of bleeding. 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. (Higher concentrations of estrogen are associated with an increased likelihood of aura, similar to the association between estrogen and seizure activity.)
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.
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 migraines are primarily caused by estrogen, the female sex hormone that specifically regulates the menstrual cycle fluctuations throughout the cycle. 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 forms 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 estrogen can also lead to migraines. Talk to your doctor about pills with low amounts of estrogen or progesterone only. They cause fewer side effects.
- 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, two female hormones, in your body drops. This drastic change can trigger throbbing headaches.
- 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: 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. 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.
The menstrual migraine´s 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:
- Throbbing pain on one side of your head
- 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
- Bigger appetite
- Lack of coordination
- Cravings for chocolate, salt, or alcohol
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
- unilateral location
- intensification of headache upon the activity
Any combination of two suffices for diagnosis—much 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.
Home Remedies and Alternative Treatments
Talk to your doctor about these options, especially supplements, which can affect the way other medications work:
- 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’s 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’t hurt, and some experts say they help with headaches, but there isn’t a lot of solid proof.
- Massage: There’s some evidence that shows it can help ease migraines, but again, doctors aren’t exactly sure how it works.
- 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’t exactly sure why.
- 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.
Estrogen supplementation with a pill, vaginal gel, or estrogen 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, usually 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.
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.
Can You Prevent These Headaches?
There are a few methods your doctor might suggest.
Hormonal: Birth control pills or estrogen 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.
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:
- A history of smoking
- High blood pressure
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
These 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.
For many women, migraines get better once their periods have finally stopped.
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.