Menstrual Migraine Headaches

Frederick R. Jelovsek MD

Migraine headaches are more common in women and 60-70% of women with migraines report some relationship with their menstrual period. Usually there is an increased frequency before, during and after menses. There is a category of migraine that is called a true menstrual migraine. This is a migraine headache that occurs regularly, each month but only between the 2nd day before the menses and the end of menstruation. Menstrual migraine is thought to occur in about 14% of women.

The reason it is important to diagnose this subcategory of migraine is because it seems to be triggered by falling estrogen (estradiol) levels at the end of the menstrual cycle. Therefore it is quite treatable with low doses of estrogen starting one to two days before menses and continuing throughout the menstrual flow. Menstrual migraine can also be a problem on birth control pills. In this case, the migraine occurs in the seven days off of the active pills (during the seven different colored inactive sugar or iron pills). This can also be treated with low dose estrogen during that seven days.

Sometimes, what is a migraine headache versus what is just a chronic tension-type headache gets confused. A recent publication, Ling FW et al (eds.): Strategies for the management of headache. Association of Professors of Gynecology and Obstetrics Educational Series on Women's Health Issues. 1998, had a good discussion of the different types of headaches in women. They organized the International Headache Society classification of headaches:

Headache Diagnostic Criteria

Migraine without aura	Migraine with aura	Chronic tension-type
At least 5 attacks fulfilling the following criteria:	At least 2 attacks having at least 3 of the following characteristics:	--
headache lasts 4-72 hours if untreated	one or more aura symptoms occur and are fully reversible	average frequency of 15 days per month for 6 months
headache includes at least two of the following characterisitcs -- unilateral location, pulsating quality, moderate to severe intensity which inhibits or prohibits daily activity, aggravation by routine physical activity	at least one aura symptom develops gradually over more than 4 minutes or 2 or more symptoms occur in succession.	at least 2 of the following pain characteristics: pressing or tightening, mild or moderate severity, bilateral location, not aggravated by physicial activity
headache is accompanied by at least one of the following -- nausea and/or vomitting, light or sound sensitivity	no single aura symptom lasts more than 60 minutes	no vomiting
--	headache begins just before or within 60 minutes of an aura	nausea, light or sound sensitivity
Plus
other disease/disorder process is ruled out or if present, migraine attacks do not occur for the first time in close temporal relation to the disease/disorder	secondary cause excluded by a medical evaluation	--

Almost one in six women are thought to suffer from migraine headaches with a peak incidence between ages 25 and 55. Of those women only about 40% have been diagnosed by a physician.