Menstrual migraines are migraine attacks that occur before and during a woman’s menstrual period. They are thought to be linked to the changes in hormone levels that occur around that time of the month, and because of that, they are sometimes referred to as hormonal headaches.
Here’s what to know about the different types of migraines that occur around menstruation and how to treat them.
Menstrual Migraine vs. Menstrually Related Migraine
There are several types of migraine, one of which is menstrual migraine. This is when a woman has migraine attacks only around menstruation, says Nada Hindiyeh, MD, a headache specialist and researcher at Stanford Health Care in Palo Alto, California.
Most women who have migraine attacks around the time of menstruation have menstrually related migraine, says Dr. Hindiyeh. “Their menstrual cycle will certainly be a trigger, but they also have other triggers or other times when they’ll get migraine [attacks].
Menstrual Migraine Is Tough to Treat
Even if you have migraine attacks only around the time of your period, for many women that may still mean five days or more a month, says Hindiyeh. “In that case, it’s really time to talk to your doctor about daily preventive treatment options for migraine,” she says.
Here’s a rundown of the top medications and lifestyle modifications that can reduce the frequency and severity of menstrual and menstrually related migraine attacks.
1. Triptans
There are also triptans that have a longer half-life. For example, frovatriptan (Frova) has a half-life of 26 hours, and naratriptan (Amerge) has a half-life of six to eight hours. “These longer-acting ones can often be used as a ‘mini-prophylaxis’ right around your period,” Hindiyeh says.
“If you know your period is a big trigger for a migraine attack, you can start taking one of those longer-acting triptans a couple of days before your period on a schedule, either every day or twice a day for a few days in a row, depending on the medication. This can prevent the migraine attack from getting so bad,” says Hindiyeh.
2. NSAIDs
Nonsteroidal anti-inflammatory drugs, or NSAIDs, such as naproxen (Aleve) and ibuprofen (Advil) can be used strategically for menstrual migraine as a prophylaxis, says Hindiyeh.
Vincent T. Martin, MD, the director of the headache and facial pain center at the University of Cincinnati Gardner Neuroscience Institute, says that 550 milligrams (mg) of naproxen taken twice a day starting six days before menstruation and ending seven days after menstruation has demonstrated effectiveness in the prevention of menstrual migraine.
3. Oral Contraceptives
“There is some evidence to suggest that certain types of oral contraceptive pills can actually reduce the frequency of menstrual migraine and menstrually related migraine,” Hindiyeh says.
This doesn’t apply to all kinds of oral contraception, so you should talk with your gynecologist, primary care doctor, or neurologist about which ones you’d want to consider, says Hindiyeh. “There are specific ones that will keep your estrogen level from fluctuating so much.” If you’re considering taking oral contraceptives as a means of birth control or to try to improve your migraine symptoms, tell your healthcare provider about your migraine history, says Hindiyeh.
4. Self-Care
If you have menstrual migraine attacks, it’s especially important to take care of yourself and try to decrease your stress level around the time of your period, says Hindiyeh.
“Keep a regular sleep schedule, which means waking and going to bed at around the same times every day. Don’t skip meals, try to eat protein with every meal, and do aerobic exercise every day for about 20 to 30 minutes,” she says.
“Making these habits a priority will help you decrease the frequency and severity of your migraine attacks,” says Hindiyeh.
5. Magnesium
“I really like magnesium as a natural supplement to take every day to help prevent menstrual migraine,” says Hindiyeh. There is evidence to support using magnesium, she says, though the mechanism of action, or the “why” behind how it improves migraine, is not totally understood. “It could be stabilizing cells or decreasing hyperexcitability or neuronal firing, but that’s all theoretical at this point.”
A variety of types of magnesium supplements can be purchased over the counter. Talk with your doctor about any supplements you are taking or are interested in taking.
6. Regular Exercise
“When we consider all the strategies to prevent migraine attacks, I love it when people choose to make lifestyle modifications that can make a real difference,” says Hindiyeh.
“There’s lots of evidence to suggest regular aerobic exercise can work as a preventive medication all on its own, and there are some studies to suggest that yoga and HIIT (high-intensity interval training) can be helpful as well,” says Hindiyeh.
“Not only can regular exercise help prevent migraine attacks for some people, but also, if the headache is mild, a short bout of exercise can actually help relieve the headache that’s happening,” says Hindiyeh.
On the other hand, overexerting yourself can be a trigger for migraine, especially if you are already having a migraine attack.
“One of the cardinal definitions and features of migraine is that normal activity can make you feel worse,” says Hindiyeh. “If you’re already in the middle of a severe migraine attack, moving around excessively is going to make things worse for you; it’s probably not the best time to go for a jog or do some aerobic activity.”
7. Beta-Blockers
Beta-blockers are medications typically used to treat high blood pressure and other cardiovascular problems. But they can also be used to prevent migraine attacks in general, and not just specifically menstrual migraine, says Hindiyeh.
“Beta-blockers, such as propranolol, are commonly used as a daily preventive for migraine. There is lots of evidence to suggest that they can decrease the severity and frequency of migraine,” she says.
Exactly how beta-blockers prevent migraine attacks is unknown. It could be mainly their effect of blocking the action of the hormones epinephrine (also called adrenaline) and norepinephrine (noradrenaline), which slows the heart and relaxes blood vessels. It may also be related to the way some beta-blockers shut down certain serotonin receptors in the brain and elsewhere in the body. Changes in serotonin levels in the brain have been linked to migraine attacks. But beta-blockers have many other effects in the body, and these are just two of the possibilities for their therapeutic effect on migraine.
If beta-blockers aren’t an option for you or don’t reduce your migraine attack frequency, there are several other classes of medications, including anti-epileptic drugs and certain antidepressants, that can be effective preventives, Hindiyeh says.
8. CGRP Inhibitors
CGRP inhibitors are among the newest drugs approved for the treatment of migraine. There are two types: CGRP monoclonal antibodies, which are given as injections or infusions and are used for migraine prevention, and CGRP receptor antagonists, which are taken as pills and are used either for prevention or acute treatment, depending on the particular product. Both target calcitonin gene-related peptide (CGRP), a protein involved in the transmission of pain.
Forty women were given CGRP monoclonal antibody injections over six months. Most of the participants took erenumab (Aimovig), but a few used galcanezumab (Emgality) or fremanezumab (Ajovy).
After six months, the researchers saw a significant reduction in the frequency, duration, and intensity of migraine attacks occurring during the perimenstrual window — defined as two days before the onset of menstruation and continuing through three days after onset. In addition, a much higher percentage of the women in the study responded to migraine painkillers within two hours of taking them.
The researchers concluded that CGRP monoclonal antibodies “could represent a safe and effective preventive therapeutic strategy” for menstrual migraine.
Hindiyeh cautions, however, that most insurance companies won’t cover a CGRP drug until a person with migraine has tried a certain number of oral preventive medications first, without good results.
In addition, she says, “With certain CGRP antibodies, specifically Aimovig, I would consider avoiding them in anyone who has hypertension or constipation, as it may make these conditions worse.”
9. Nerve Stimulation
For women who would like an alternative to pharmaceuticals, nerve stimulation devices may be worth a try. Some of these devices are approved just for acute treatment, and some for both acute and preventive care.
The Takeaway
- Women often experience migraine attacks around the time of their menstrual period; this is thought to be related to the drop in estrogen.
- There are two types of migraine that can occur: Menstrual migraine, which only occurs around the monthly period, and menstrually related migraine, which affects women who also experience migraine attacks at other times.
- Medications and lifestyle measures have been found to relieve or improve migraine attacks around the time of menstruation.
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