Migraine associated with periods (menses)

NICE state with respect to Menstrual (catamenial) related migraine (1):

• suspect menstrual-related migraine in women and girls whose migraine occurs predominantly between 2 days before and 3 days after the start of menstruation in at least 2 out of 3 consecutive menstrual cycles
• diagnose menstrual-related migraine using a headache diary for at least 2 menstrual cycles
• for women and girls with predictable menstrual-related migraine that does not respond adequately to standard acute treatment, consider treatment with frovatriptan (2.5 mg twice a day) or zolmitriptan (2.5 mg twice or three times a day) on the days migraine is expected.
  
  

Notes (2):

• a proportion of women suffer from migraine attacks in association with the menstrual cycle, termed menstrual related migraine (MRM). MRM occurs between days -2 and +3 of the first day of menstruation (which is +1) in at least 2 out of 3 menstrual cycles
  • women with MRM will also have attacks at other times
  • less than 10% of women report migraine exclusively with menstruation and at no other time ('pure' menstrual migraine)
• targeted oestrogen supplementation
  • menstrually targeted oestrogen supplementation (assuming no contraindications) has been found in some studies to offer benefit in menstrual related migraine
  • however, a rebound increase in migraine attack frequency has been found when the effect of this strategy has been considered over the whole menstrual cycle
  • risk of stroke in migraine with aura, when taking oestrogen-containing contraceptives
    • females suffering migraine with aura have an inherent increased risk of stroke
    • use of the oestrogen contraceptive pill is also associated with increased risk of stroke in all individuals. The incidence of stroke in females with migraine with aura, who are also taking the oestrogen-containing contraceptive pill is additionally increased
      • consequently, contraceptive methods other than oestrogen containing contraception are advised for women with migraine with aura. There is no established additional risk in migraine without aura

Reference:

1. NICE (December 2021). Headaches - Diagnosis and management of headaches in young people and adults
2. British Association for the Study of Headache (BASH) guidelines, 2019.