Migraine and Periods
Menstrual Migraine

What is migraine?

Migraine is a condition that causes episodes ('attacks') of headaches, and often other symptoms such as feeling sick or vomiting. Between migraine attacks, the symptoms go completely.

This leaflet is about migraines that occur around the time of menstrual periods. It is assumed that you have some general knowledge about migraine, but would like to know more about this aspect of migraine. (A leaflet called 'Migraine' gives general details about migraine.)

How do periods affect migraine?

In most people who have migraine, most attacks 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, migraines occur during periods. The actual cause of the trigger is thought to be the fall of the level of the hormone oestrogen. The blood level of this hormone falls just before a period. It is not a low level of oestrogen that is the trigger, but the fall from one level to another.

The strict definition of menstrual migraine is for the migraine to start anytime from two days before, to three days after the first day of a period. Also, that a migraines occurs around most (or all) periods. There are two types of patterns.

• Pure menstrual migraine is when migraine occurs only around periods, and not at other times. This occurs in about 1 in 7 women who have migraine.
• Menstrual-associated migraine is when migraines occur around periods, and at other times of the month 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 migraines 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 the number of migraines tends to reduce.

Women who take the combined contraceptive pill 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 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 migraines, 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 cause of migraine. That is, options include: painkillers, anti-inflammatory painkillers, anti-sickness medicines, and triptan medicines. See leaflet called 'Medicines to Treat Migraine Attacks' for details.

Treatment options for preventing menstrual migraine

Some women have severe menstrual migraines, 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 migraines. The migraines 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.

Anti-inflammatory painkillers
They include mefanamic acid, naproxen, ibuprofen, diclofenac, etc. These are painkillers which can be used to treat migraine attacks. However, some women take a short course of one of these medicines starting as soon as the period starts 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.)

Oestrogen supplements
Topping up your level of oestrogen just before and during a period is an option. This works as 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 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 onto your skin for the seven days. This too is absorbed into the bloodstream.

Combined contraceptive pill and migraines
If you have or develop migraine with aura, you should not take the combined contraceptive pill at all. (See leaflet called 'Migraine' for an explanation of 'migraine with aura'.) However, it is common to have migraines without aura during the period between pill packs (when you have the withdrawal bleed in the pill-free interval). If this occurs, options to consider which may prevent these migraines are:

• Changing to a pill with less progestogen (if you take one with a high dose). Migraines 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 less withdrawal bleeds per year, and therefore less migraines.
• Oestrogen supplements can be used during the seven-day pill-free interval.
• A change to a different method of contraception.

Further sources of help and information

Migraine Action  Tel: 01536 461333   Web: www.migraine.org.uk

Migraine Trust  Tel: 020 7436 1336   Web: www.migrainetrust.org

© EMIS and PIP 2005   Updated: February 2005   Review Date: July 2006   CHIQ Accredited   PRODIGY Validated