MIAMI BEACH — Up to 70% of women who experience migraines have exacerbations during menstruation, and another 7%–14% of female migraineurs experience only menstrually related migraines.
Reducing the drop in estrogen levels that occurs at menses—whether the drop is endogenous or exogenous—can help these women, Dr. Susan Hutchinson said at a symposium sponsored by the American Headache Society.
In women on oral contraceptives who experience migraine without aura, add-back estrogen delivered perimenstrually when cycling off the active pills may help prevent menstrual migraines. Add-back estrogen can also prevent the endogenous drop in ovarian estradiol production in women not using hormonal contraception who have menstrual migraines.
Physicians might consider using a 0.1-mg dose delivered via estradiol patch during the week of menses, said Dr. Hutchinson, a family physician and headache specialist in private practice in Irvine, Calif. Lower doses tend to be less effective for this purpose, she added.
Young female migraineurs who ask for oral contraception should be advised of the “one-third rule,” which is that about a third of migraineurs who start on oral contraception experience improvements, about a third have no change, and about a third have deterioration.
However, the best options in those with regular menses include low-dose (35 mcg of estrogen or less) monophasic birth control pills, or contraception delivered via a contraceptive ring.
For prevention in those who still have menstrual migraines, physicians should consider continuous monophasic contraception or continuous contraception via vaginal ring with estradiol add-back when cycling off.
However, Dr. Hutchinson warned that the World Health Organization and the American College of Obstetricians and Gynecologists consider estrogen-containing contraception contraindicated in women who have migraine with aura, because studies have shown an increased stroke risk in this population.
The risk is further increased in those who use hormonal contraceptives and who have other risk factors such as smoking, hypertension, and dense aura.
In women who experience aura only rarely, the benefits of estrogen-containing contraception may outweigh the risks, so treatment decisions should be made on an individual basis, Dr. Hutchinson said.
In those who experience aura with migraine, options include progesterone-only oral contraceptives, implants, or injections, and progesterone or copper IUDs.
All migraine patients whose hormonal status is altered should keep a journal or calendar tracking headaches to ensure appropriate treatment, she noted.
“Understanding the relationship between hormones and migraine is instrumental. … If we really want to help our women migraineurs, particularly the 60%–70% [whose headaches worsen] during the time of their period,” said Dr. Hutchinson.
Preventive Strategies MayWork for Nonresponders
Women with menstrual migraines who fail to respond adequately to hormonal manipulation may benefit from short-term or minipreventive treatment approaches, Dr. Hutchinson said.
For example, NSAIDs given for short periods or just before menstruation can be helpful for reducing frequency and/or severity of migraines. Triptans are also useful for menstrual migraines, but many women who use triptans express concerns about having to use so many for this indication, because menstrual migraines tend to last longer and have greater severity than other migraines. In these patients, combining hormone manipulation with triptan treatment may help.
Combining an NSAID and triptan can also be a useful approach; some patients report that this combination works even better and faster than triptans alone.
Magnesium has also been shown to have some preventive benefit when given at 400 mg during the luteal phase or daily (a simpler approach). Increasing the dose of daily preventive medications around the time of menstruation can also be useful, Dr. Hutchinson said.