Menstrual Migraine: Therapeutic Approaches

Menstrual migraine is common, affecting at least 50% of female migraine sufferers. Women who suffer from menstrual migraine typically experience a degree of fluctuation in their migraine intensity as well as a varied degree of association between their migraines and their menstrual cycles throughout the years. 

The most commonly accepted treatment approaches for menstrual migraine are largely similar to the treatment of migraine in general. However, this large population subset can potentially benefit from therapies that are more directly targeted to hormonally-influenced migraine headaches. 

The Most Effective Treatments for Menstrual Migraine

Overall, studies point to the use of triptans as the most effective class of pharmacologic treatment for acute migraine. Ergotamines have also been shown to be effective, although many physicians, particularly non-neurologists, hesitate to prescribe them due to lack of familiarity with the side effect profile.

Preventative medications include antidepressants, propranolol, and anticonvulsants. Hormonal treatments, either in the form of contraceptive pills or other hormonal combinations, are used for some patients, with a degree of success. However, the cyclical nature of menstrual migraine may make the use of daily preventative therapies seem excessive to some patients, particularly if they do not experience pain for most days of the month.

Non-Prescription Treatments for Menstrual Migraine 

Given that this patient population is quite large, many patients who experience menstrual migraines are otherwise healthy and express a strong interest in attempting to prevent or manage their migraine headaches without the use of prescription strength medications. 

Some non-pharmacological therapies that have shown promise in the prevention of menstrual migraine headaches include magnesium supplements and/or Vitamin E. The mode of action of magnesium in migraine is not specifically clear or hormonally correlated, but some studies show that there may be a diminished magnesium level in association with migraine headaches. Vitamin E is a progesterone antagonist, and therefore has been proposed as a potential treatment for menstrual migraines because of the progesterone fluctuations that occur during the menstrual cycle. 

Cathodal treatment is another interesting approach to the prevention of menstrual migraine, involving externally placed electrode-mediated stimulation of the visual cortex. A small study demonstrated an improvement in menstrual migraine with the use of cathode stimulation, but it did not clearly demonstrate superiority to placebo.  

Non-Pharmacological Treatment of Menstrual Migraine for Patients

While neurologists do not typically recommend vitamin supplementation in the absence of a documented, clinically significant vitamin deficiency, patients often ask about vitamin supplementation, particularly for the treatment of non life-threatening conditions such as menstrual migraine. Given the debilitating nature of migraine headaches, most patients are agreeable to prescription medications and are compliant with instructions. Yet, for a variety of reasons, some patients are unable to tolerate medications due to side effects, particularly the preventative medications. 

Have you ever recommended non-prescription therapy for migraine prevention for your patients who suffer from menstrual migraine?

References:

Rajapakse T, Pringsheim T. Nutraceuticals in migraine: a summary of existing guidelines for use. Headache. 2016 Apr;56(4):808-816.

Wickmann F, et al. Prophylactic treatment in menstrual migraine: a proof-of-concept study. J Neurol Sci. 2015 Jul 15;354(1-2):103-109.