Controlling Estrogen Levels May Treat Menstrual Migraine

Manipulation of Estrogen Levels

Corroborating evidence was found in a study that looked at hormone-related symptoms in 262 oral contraceptive users. Headache occurred significantly more frequently during the one-week hormone-free interval than during the three active-pill weeks, Dr. Calhoun noted. “Typical contraceptive treatment consists of a low-dose 20-µg ethinyl estradiol pill (combined with a progestin) for 21 days, followed by seven days of placebo,” she said. “A 20-µg drop in ethinyl estradiol (the estrogen in most oral contraceptives) is enough to cause a migraine, but if you limit that to a 10-µg drop, you can prevent migraine.”

Therefore, a patient on a 20-µg pill should be prescribed a 10-µg dose of ethinyl estradiol in the fourth week, Dr. Calhoun explained. If she is on a 30-µg pill, a 20-µg dose of ethinyl estradiol would be needed in the fourth week. “Continual hormonal combined contraceptives (with no placebo days) are also a good solution, so long as she does not have breakthrough bleeding,” she added.

Dr. Calhoun and colleagues examined the patient records of 229 consecutive women who were prescribed hormonal prophylaxis for MRM. Three hormonal preventive strategies were used: low-dose oral contraceptive with supplemental estrogen during the menstrual week; extended-cycle oral contraception with supplemental estrogen in the menstrual week; or a natural menstrual cycle with perimenstrual application of an estradiol patch two days beforethe expected onset of bleeding and continued for a week. In all, 168 women had resolution of MRM, 40 had persistence of MRM, and 21 refused or discontinued hormonal prophylaxis. Resolution of MRM was associated with a reversion to episodic migraine, resolution of medication overuse, and an overall decreased consumption of triptans, opioids, acute agents, and migraine preventive medication.

—Adriene Marshall

Suggested Reading

Calhoun A, Ford S. Elimination of menstrual-related migraine beneficially impacts chronification and medication overuse. Headache. 2008;48(8):1186-1193.

MacGregor EA, Hackshaw A. Prevalence of migraine on each day of the natural menstrual cycle. Neurology. 2004;63(2):351-353.

Silberstein SD, Massiou H, Le Jeunne C, et al. Rizatriptan in the treatment of menstrual migraine. Obstet Gynecol. 2000;96(2):237-242.Stewart WF, Lipton RB, Chee E, et al. Menstrual cycle and headache in a population sample of migraineurs. Neurology. 2000;55(10):1517-1523.