As if having a period isn't enough, some women also suffer migraines during their "time of the month." Aptly named menstrual migraine, this condition is triggered solely by shifting estrogen levels that may interact with serotonin or other brain chemicals to cause head pain and migraine other symptoms.

It makes sense, then, that nearly 70% of migraineurs are women. Of that group, 60% and 70% report a connection between their menstrual cycle and migraine attacks. Unfortunately, menstrual migraines may not respond as readily to typical treatments and preventatives. 

What does a menstrual migraine feel like? It feels like most other migraines, but it’s piled on top of menstrual pain and discomfort.

A Menstrual Migraine Is…

Migraines are neurological diseases with symptoms that include debilitating pain on one side of the head that pulses or throbs. A menstrual migraine occurs up to three days before a woman's period through three days during the period. 

The migraines may worsen with movement, light, odors, or sound, just like other migraines. Also, the migraines may last from a few hours to a few days. 

Estrogen and progesterone are essential sex hormones created in the ovaries and regulate the menstrual cycle. Estrogen controls the expression of female features, aids in reproduction, and kicks off puberty. Estrogen also affects cholesterol, the heart, the brain, and other tissues, and protects bone health.

Symptoms of a Menstrual Migraine

Menstrual migraine pain ranges from dull to severe throbbing. You may feel too warm and sweat or feel cold and get the chills. You may be sensitive to light, noise, and smells. You may have a tender scalp, lose your appetite, feel dizzy, or have blurred vision. 

Many migraineurs feel fatigued and show pallor (pale skin). Some suffer nausea, vomiting, stomach upset, and abdominal pain (along with menstrual cramps).

Dropping estrogen levels are to blame for migraine attacks. Estrogen rises at the beginning of a cycle to ready to body for pregnancy. Then, during the cycle’s course, estrogen begins to drop, setting off migraines in susceptible women.

Diagnosing Menstrual Migraines

As with most migraines, a thorough history and medical checkup help your physician diagnose menstrual migraines. Be ready to describe the severity, location, and type of head pain (throbbing or pulsing).

Your doctor will want to know how often you have migraine attacks and if anything relieves the head pain, including medications you take to relieve pain. You will also talk about activities, foods, stressors, or other situations that might trigger migraines. 

Does anyone else in your family suffer migraines? There are genetic factors that lead to migraines within families. Also, how do you feel before, during, and after the migraine? The answer to this and other questions helps your healthcare provider narrow the diagnosis to menstrual migraine.

You may have a CT scan or MRI to rule out tumors and an EEG (electroencephalograph) to rule out seizures. 

If you keep a migraine diary or journal, take it with you. It should describe your symptoms, how long they last, and anything that impacts severity.

Treating and Managing Menstrual Migraines

Treatments include acute medications, “mini-preventatives,” and continuous preventatives. 

Acute treatments are fast-acting medications taken by mouth, injected, or inhaled as a nasal spray, which are taken early in a migraine attack. Often, they are combined with non-steroidal anti-inflammatory drugs (NSAIDs) such as naproxen sodium or ibuprofen. 

Oral medications include the following:

• Sumatriptan 
• Rizatriptan 
• Zolmitriptan 
• Almotriptan 
• Eletriptan 
• A combination of aspirin, acetaminophen, and caffeine (AAC)

Injectables work more quickly than oral medications and include:

• Sumatriptan (the only triptan available as an injectable)

• Dihydroergotamine (DHE)

Injectables have the advantage of bypassing the stomach, so if you have nausea or vomiting, you are less likely to eject the treatment before it can work.

Nasal triptans are also faster than pills and avoid the problems with vomiting and nausea. Zolmitriptan, sumatriptan, and DHE are available as nasal sprays. Taking medication nasally may be more comfortable and acceptable than injections.

Mini-preventives are medications taken when the threat of migraines is highest. You may take them for five to seven days in a row during a specific part of your cycle. These medications include:

• NSAIDs
• Hormones - estrogen supplements during the menstrual week to prevent a drop in estrogen. They are available as pills, vaginal gel, and patches.
• Triptans dosed twice daily throughout the period.
• Magnesium started on day 15 of the cycle, or 15 days from the start of the period, and continuing until it ends.

Hormone supplements work best for those with regular periods. Birth control pills are a popular method of taking estrogen — you simply replace the inactive pills with estrogen pills. 

Magnesium works well for those with irregular periods because it depends on an individual’s cycle.

Continuous preventatives work best with regular cycles. You take them beginning a few days before your period and continue for up to two weeks after your period begins. The same estrogen supplements used as mini-preventatives are also available for continuous management.

You can take other daily medications to prevent migraines, increasing the dosage as your period nears. They include oral contraceptives, NSAIDs, triptans, methylergonovine, DHE, magnesium, fluoxetine, and estradiol.

For some women, oral contraception may change migraine patterns, and not always positively. A lower dose estrogen pill is less likely to trigger migraines when you begin taking the inactive pills. 

An alternative is to eliminate the inactive pills in favor of extended cycle estrogen-progesterone pills or use low-dose estrogen pills to reduce the drop in hormone level.

Also, you might consider taking NSAIDs or triptans during inactive pill days or an estrogen skin patch during that week.

Pregnancy and Migraines

Before attempting to become pregnant, or if you are pregnant and suffer migraines, speak with your doctor before beginning any course of medication. Many of the treatments for migraine are harmful to the developing fetus. 

Since estrogen levels rise rapidly and remain high during pregnancy, you might not suffer as many migraine attacks, and you can avoid harmful medications. Ask about safe alternatives and be ready for a potential migraine attack after birth when the estrogen level drops quickly. 

If you intend to breastfeed, discuss acceptable treatments that won’t pass to your baby in breast milk.

Summary

Many women suffer migraines triggered by the reduction in estrogen that occurs before their period begins. A thorough medical history can help your doctor diagnose a menstrual migraine and provide appropriate acute and preventative treatment. 

If you believe your migraines are connected to your menstrual cycle, consult your doctor for diagnosis and treatment. There is no reason to add migraines to the discomfort of Aunt Flo’s visits.