Migraine attacks (episodes) are often triggered by periods. Treatment of each migraine attack is no different to usual. However, there are treatments (detailed below) that may prevent period-related migraine attacks from occurring.
What is migraine?
Migraine is a condition that causes attacks (episodes) of headaches, and often other symptoms such as feeling sick (nausea) or being sick (vomiting). Between migraine attacks, the symptoms go completely.
This leaflet is about migraines that occur around the time of menstrual periods. This is sometimes called menstrual migraine. It is assumed that you have some general knowledge about migraine, but would like to know more about this aspect of migraine. (See separate leaflet called Migraine for general details about migraine.)
How do periods affect migraine?
In most people who have migraine, most attacks (episodes) of migraine occur for no apparent reason. However, something may trigger migraine attacks in some people. Triggers can be all sorts of things - for example, foods, stress, wine, etc.
For some women, migraine attacks occur during periods, or just before periods. The cause or trigger is thought to be the fall of the level of oestrogen. The blood level of this chemical (hormone) falls just before a period. It is not a low level of oestrogen that is thought to be the trigger. Rather, the trigger is thought to be the fall in the level of oestrogen from one level to another.
The strict definition of menstrual migraine is for the migraine attack to start at any time from two days before, to three days after the first day of a period. Also, that a migraine attack occurs around most (or all) periods. There are two types of patterns:
- Pure menstrual migraine occurs when migraine attacks happen only around periods, and not at other times. This occurs in about 1 in 7 women who have migraine.
- Menstrual-associated migraine occurs when migraine attacks happen around periods, but also happen at other times too. About 6 in 10 women who have migraine have this type of pattern.
Symptoms usually improve if you become pregnant, when there is a constant high level of oestrogen. As you approach the menopause, the migraine attacks may become more frequent as the level of oestrogen tends to go up and down at this time. However, once past the menopause, you have a constant stable low level of oestrogen, and migraine attacks tend to reduce.
Women who take the combined oral contraceptive pill (COCP) have a fall in oestrogen in the pill-free week between pill packets. This is when the period or withdrawal bleed occurs. This fall in oestrogen may also trigger a menstrual migraine.
How is menstrual migraine diagnosed?
Sometimes a period and a migraine attack (episode) occur at the same time by chance. Therefore, to make the diagnosis, a doctor may ask you to keep a migraine diary for three months or so. This helps to see the pattern of your migraine attacks, and whether you have menstrual migraine.
What are the treatment options for each migraine attack?
The treatment options are the same as for any other migraine attack (episode). That is, options include: painkillers, anti-inflammatory painkillers, antisickness medicines, and triptan medicines. See separate leaflet called Medicines to Treat Migraine Attacks for details.
Treatment options to prevent menstrual migraine
Some women have severe menstrual migraine attacks (episodes), and treating each attack does not work so well. In this situation, you may wish to consider a treatment that aims to prevent the migraine attacks. Your doctor may suggest one of the following. But bear in mind, treatment may not completely prevent all the migraine attacks. The migraine attacks may become less frequent and less severe. It may be useful to continue with a migraine diary to compare before and after treatment. It is usual to try any treatment for three periods to judge how well it is working.
These include mefenamic acid, naproxen, ibuprofen and diclofenac. These are painkillers which can be used to treat each migraine attack once it occurs. However, an option is to take a short course of one of these medicines each period to try to prevent (pre-empt) a migraine attack. That is, to take the medicine for a few days whether or not a migraine has occurred, in order to prevent an attack. You can start taking the tablets as soon as the period starts, or even start a few days prior to an expected period. Take them until the last day of bleeding. A short course of an anti-inflammatory painkiller is also used to treat period pain and heavy periods. Therefore, this may be a particularly good option if you also have one of these other common problems.
Some people cannot take anti-inflammatory painkillers - for example, people with a duodenal ulcer, and some people with asthma. Side-effects are uncommon if you take an anti-inflammatory painkiller for just a few days at a time, during each period. However, read the leaflet that comes with the tablets for a full list of possible cautions and side-effects.
Topping up your level of oestrogen just before and during a period is an option. This works because the trigger is thought to be a fall in the blood level of oestrogen before a period. Oestrogen skin patches are sometimes used. You put the patches on your skin for seven days starting from three days before the expected first day of your period. The oestrogen travels through the skin into the bloodstream. This is like having hormone replacement therapy (HRT) just for seven days each month. Unlike long-term HRT, provided that you are having regular periods, you do not need an additional progestogen medicine with the oestrogen. An alternative is to use an oestrogen gel that you rub on to your skin for the seven days. This too is absorbed into the bloodstream.
Note: strictly speaking, oestrogen supplements are not licensed for the treatment of menstrual migraine. However, many doctors are happy to prescribe them off licence for this condition.
Contraceptives as a treatment
Hormonal contraceptives are a useful option if menstrual migraine is a problem and you also need contraception.
- The COCP (the pill) or contraceptive patch (the patch). However this is not suitable for some women (see below).
- Progestogen-based contraceptives that prevent ovulation:
- If ovulation is prevented then there is no drop in the oestrogen level to trigger a migraine attack.
- These include desogestrel (a progestogen-only contraceptive pill - trade name of Cerazette®), the contraceptive implant (Nexplanon®), or the contraceptive injection.
- Most women with migraine at any age can use progestogen-based contraceptives - even if they have migraine attacks with aura.
- The only time they would not be advised to is if they only started to develop migraine attacks with aura after starting to take one of these types of contraceptive.
The COCP (the pill), the contraceptive patch (the patch) and migraine
If you have or develop migraine attacks with aura, you should not take the COCP or use the contraceptive patch at all. If you have migraine attacks without aura you should not take the COCP or use the contraceptive patch if you are aged 35 or older. (See separate leaflet called Migraine' for an explanation of migraine with aura.)
Some women who take the pill or have the patch have migraine attacks without aura during the period between pill packs or patches (this is the time when you have the withdrawal bleed in the pill-free or patch-free interval). If this occurs, options to consider which may prevent these migraine attacks are:
- Changing to a pill with less progestogen (if you take one with a high dose). Migraine attacks during the pill-free interval seem to occur less often in women who take a pill with a lower dose of progestogen.
- Tri-cycling. This means taking the pill continuously for three packets (nine weeks) without any breaks, followed by a seven-day pill-free interval. This keeps the level of oestrogen constant whilst you take the three packets. By doing this you will have fewer withdrawal bleeds per year, and therefore fewer migraine attacks. Note: you can only do this with pill types that have a constant dose of progestogen for each dose. These are the commonly used types, but check with your doctor or nurse if you are unsure.
- Oestrogen supplements can be used during the seven-day pill-free or patch-free interval (as described earlier).
- A change to a different method of contraception.
Further reading & references
- Migraine; NICE CKS, August 2013
- UK Medical Eligibility Criteria for Contraceptive Use; Faculty of Sexual and Reproductive Healthcare (2009)
- Diagnosis and Management of Migraine, Tension-Type, Cluster and Medication-Overuse Headache; British Association for the Study of Headache (BASH) Guidelines, (2010)
- Headaches: diagnosis and management of headaches in young people and adults; NICE Clinical Guideline (September 2012)
Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.
Dr Tim Kenny
Dr Colin Tidy
Dr John Cox