Menstrual Headache

ICDH-II defines menstrually related migraine without aura as occurring between days -2 and +3 in at least 2 out of 3 menstrual cycles. The first day of menstruation is day 1 and the preceding day is -1; there is no day 0. It is estimated that 60 % of women migraineurs have menstrual migraine without aura.

Many women would say, especially during their younger years of menstruation and before they are anywhere near menopause that they have fairly regular cycles, often times predictable to the day. Other women are not so orderly on the date the cycle comes and may be off a day or several days, or they may not even have a menstrual cycle every month. These “menstrual migraines” are often the worst and most disabling headache the migraine patient may suffer each month. They will say the pain is more intense, and the associated symptoms of nausea and vomiting, and sonic and photic sensitivity are worse. They are more likely to be confined to their bed with this particular migraine and may miss work or be out of their lives.

Menstrual attacks are chiefly migraine without aura type headache. Women who have both migraine with and without aura usually only have migraine without aura attacks with menstruation. One theory regarding menstrual attacks is that they result from estrogen withdrawal.

Typical monthly hormonal levels¬†Menstrual migraine without aura flares during times of hormonal fluctuations during the reproductive years but is less active during times of hormonal stability such as before menarche or after menopause. As a woman goes through life’s stages, her hormonal status has a great effect on migraine. Menstruation, pregnancy, the use of oral contraceptives, menopause, and hormone therapy influence the incidence and management of migraine.

Tozer,l3Q] et al, writing in the Mayo Clinic Proceedings in 2006 on “Prevention of Migraine in Women Through out the Life Span,” stated:

Fluctuating hormone levels may exacerbate migraine during perimenopause, making the menopausal transition particularly challenging for female migraineurs.

ICDH II recognizes that some women only have menstrually related headache but no migraine at other times during their cycle. This is called pure menstrual migraine without aura and comprises 14% of women with migraine. Women who have attacks at menstruation and also at other times during the cycle are called menstrually-related migraine without aura. The importance of the pure menstrual migraine group is that some studies show that hormone prophylaxis may be more effective for this type of migraine.

A lay myth is that “migraine goes away at menopause.” Long term studies do not support this myth. Whitty and Hockadayl reported on what happens to patients with migraine in their article in the British Medical Journal in 1968 entitled, “Migraine: a Follow-up Study of 92 Patients.” They start their article with the following comments: It has been a commonly held view that migraine attacks tend to cease as time passes and that such improvement occurs particularly after the menopause in women. However, we have found no published work

on the natural history of the condition over periods of more than a few years which might lend support to this view. We therefore studied a group of migraine patients followed for periods of 15 to 20 years who, when finally assessed, had been subject to the condition for 16 to 69 years. We inquired for changes in frequency and severity of attacks and in the pattern of individual attacks, and sought to find out if these showed any consistent relation to advancing years, to the menopause, or to intercurrent illness, especially the development of hypertension or cervical spondylosis. In conclusion Whitty and Hockaday stated: We found no evidence to support a commonly held view that migraine improves or ceases with the menopause. Most of our cases showed no change; rather more were worse than better. One patient started her attacks, which we believed to be true migraine by the usual criteria, at the menopause. These same women may have an increase in frequency, intensity, and type of migraine attacks with the use of birth control pills or estrogen. Other women with migraine may notice no particular relationship to their menses or estrogen levels. This is likely due to different genes for migraine.