Menstrual Migraine and Treatment Options: Review

Kasra Maasumi, MD, MS; Stewart J. Tepper, MD; Jennifer S. Kriegler, MD


Headache. 2017;57(2):194-208. 

In This Article

Abstract and Introduction


Objective. A review of treatment options for menstrual migraine.

Background. Migraine affects ~30 million people in the US. A subset of female migraineurs have migraines that are mainly associated with menstruation. Menstrual migraine (MM) is divided into pure MM and menstrually related migraine. Pure MM attacks occur only with menstruation and have a prevalence of 1%. Menstrually related migraine has a prevalence of 6–7%, and occurs both during menstruation as well as during the rest of the cycle. MM is usually without aura and is more severe, longer lasting, and more resistant to treatment due to the effects of ovarian hormones, specifically estrogen. MM treatment is divided into acute, short-term prophylaxis, and daily prevention. The best-studied acute treatments are triptans. For short-term prophylaxis, triptans, non-triptans, or combinations are used. Some preventive medications may be used daily to prevent MM. Many anti-epileptic medications used in migraine prevention can affect the efficacy of oral contraceptives and hormonal treatments, so caution is indicated when these are used.

Methods. PubMed, Scopus, Cochrane, and Embase were searched for MM and treatments.

Results. Many randomized, placebo-controlled, prospective studies have evaluated the efficacy of sumatriptan, rizatriptan, naratriptan, zolmitriptan, and almotriptan in MM. Reviewing numerous studies with statistically significant results, rizatriptan has the best overall evidence for acute treatment of MM, ranging from pain-free responses of 33–73% at 2 hours. Sumatriptan and rizatriptan have shown similar efficacies of 61–63% in terms of 2 hour pain freedom. Rizatriptan showed sustained pain relief between 2 and 24 hours with an efficacy of 63% and sustained pain freedom for MM between 2 and 24 hours with an efficacy of 32%. For short-term prevention of MM, there were four randomized controlled trials for frovatriptan taken twice daily, one trial for zolmitriptan taken three times daily, and two studies for naratriptan taken twice daily, all of which showed statistically significant results. Among studies on non-triptans for short-term prevention of MM, magnesium, estrogen, naproxen sodium, and dihydroergotamine all had statistically significant results. Many antiepileptic medications taken for prevention of MM can cause enzyme induction affecting oral contraceptives (OCs) and hormonal treatments to different degrees. Topiramate has the least effect on OCs at doses below 200 mg/day. Lamotrigine noticeably decreases oral contraceptive levels; however, the evidence for it as a preventive medication is not strong.

Conclusion. MM can be very difficult to treat. For acute treatments, rizatriptan has the best overall evidence. For short-term prevention, frovatriptan, zolmitriptan, or naratriptan, as well as magnesium, estrogen, naproxen sodium, or dihydroergotamine may be useful.


This narrative review will summarize the published literature regarding menstrual migraine (MM), including topics such as epidemiology, clinical characteristics, and some treatment options. Using relevant evidence-based randomized controlled studies, we divide the treatment options for MM into acute treatment and short-term prevention with triptans and non-triptans. We then conclude with a brief description of the interaction between estrogen and antiepileptic medications that are used as daily preventive medication in MM.

There is a sub-population of female migraineurs who have migraines associated with menstruation. According to the International Classification of Headache Disorders, 3rd edition Beta version (ICHD-3β), MM is often without aura. It is subdivided into menstrually related migraines (MRM) and pure menstrual migraines (PMM). By convention, the first day of menstrual flow is labeled as day (+1). There is no day 0 (zero). PMM often occurs between days −2 and +3 of menstrual cycle. On the other hand, MRM can occur not only between days −2 and +3 but can also occur at other times of the menstrual cycle.[1]

In a population-based study done by Vetvik et al., MM occurred in 22% of female migraineurs and 7.6% of general population.[2] In this article, they also reviewed the epidemiology of MM in other population-based studies from 1975 to 2012 and found that among migraineurs, 0.85–14.1% have PMM, 3–71.4% have MRM, and 3.85–78.6% have MM. These values have a wide range representing methodological differences including different definitions of MM.

Clinically, both PMM and MRM are more severe, longer in duration, and are more resistant to treatment than non-MMs.[3] Stewart et al. showed that the pain intensity, disability score, and duration of migraine are most severe during the first 2 days of menses compared to other headache types.[4]

In summary, MM is very prevalent and difficult to treat. It is important for clinicians to recognize it and know about the various treatment options available for management.