If you get migraine headaches you are certainly not alone – some 36 million Americans, or 12 percent of people 12 years old and older suffer from migraine attacks. And, if you are a woman, you are three times more likely to have migraines than a man. Migraines can have many triggers, but it turns out ladies, menstruation is arguably the most prevalent trigger. In fact, 60-70% of women who have migraines report a menstrual association with their headaches. Migraines that occur during the peri-menstrual time period are referred to as Menstrually Related Migraine or MRM.
Well-Being turned to Christina Treppendahl, RN, MSN, FNP-BC, of The Headache Center and Ms. Mickie Autry, PhD, NP-C, Menopause & Sexual Wellness Nurse Practitioner of Ovation Woman’s Wellness, for more about MRM and how women can get help, if they believe they are suffering from hormone-related headaches.
Estrogen is a hormone that is primarily produced by a woman’s ovaries.
According to Ms. Treppendahl, studies have revealed that the decline of estrogen during menses can be a strong trigger for migraine.
It is believed that migraines are caused by a release of neurotransmitters (chemical messengers) through nerve endings in the brain. When estrogen levels drop and a migraine attack is triggered, the blood vessels lining the brain become dilated and inflamed.
“This drop in estrogen happens during the natural menstrual cycle, and also during the placebo week for women taking birth control pills containing forms of estrogen,” explains Treppendahl. “It can happen at any age between menarche (the first occurrence of menstruation) and menopause.”
“Many females experience their first migraine after they begin having periods,” continues Treppendahl. “As estrogen levels tend to increase during puberty, so does the frequency and prevalence of migraine during these years.”
“Hormone fluctuations significantly trigger the onset of headaches in many women,” interjects Autry. “In the teen years headaches are unpredictable as hormone levels are erratic. Once a young woman’s cycles become regular due to hormone cyclical release, headaches usually occur from two days prior to the onset of the menstruation, through day three of her period.”
Migraine peaks in women during their childbearing years. Seven percent of women experience their first migraine with pregnancy. Seventy-five percent of women report improvement in their migraines during pregnancy, especially during the second and third trimester when estrogen levels have peaked and plateaued. In a large clinical review of pregnant migraineurs, women reported a 60-70% improvement in migraine during pregnancy. Miraculously, 20% reported a complete resolution of migraine attacks during pregnancy. It is suspected that this is related to the high steady state of estrogen during pregnancy. However, after delivery and lactation, the migraines tend to recur within a month or two.
“Menstrual-related migraine can be a challenge to treat,” notes Treppendahl. “Oftentimes, conventional migraine treatment strategies do not offer significant or satisfactory relief to sufferers.”
Conventional strategies to treat migraine not associated with menstruation include:
Lifestyle modification. Avoiding triggers (certain foods, skipping meals, taking naps, poor sleep hygiene, drinking alcohol – just to name a few); exercising; staying well hydrated; stress management (psychological counseling and cognitive behavioral therapy) and weight management.
Preventive Therapies. Certain medications may be taken daily to decrease frequency and severity of migraines. These include certain FDA-approved anti-seizure drugs, antidepressants or blood pressure medications. Many new preventive medications and devices are in development.
Abortive Therapies. These medications are taken at the onset of a headache to terminate a migraine and restore a patient to normal functioning and minimize disability. These typically include non-narcotic analgesics like NSAIDs, triptans (a migraine-specific drug that targets neurotransmitters in the brain) and anti-nausea medications.
“If conventional medications fail to be effective during several attempts over several cycles,” adds Treppendahl, “a more aggressive approach may include individual medications, or a combination of therapies.”
More aggressive therapies for MRM include:
Naproxen sodium taken twice daily during the peri-menstrual period. Studies have shown that 550 mg taken twice daily a few days before the menstrual migraine is expected can greatly reduce the severity of the headache. It also can make treatment of the headache with triptans work better without allowing the headache to rebound, and in some patients, it may actually prevent the MRM.
Triptans taken once or twice daily during the peri-menstrual period. Frovatriptan (Frova), naratriptan (Amerge) and zolmatriptan (Zomig) have data showing benefit during the peri-menstrual time period. However, because most insurance plans allow only 6 – 12 pills per month, someone having 15 or more headache days potentially could run out of medication for the month after 4 – 6 headaches.
Vitamin E supplementation. Daily supplementation with 400 IU vitamin E has been shown to be beneficial in one small clinical trial.
Supplementing estrogen with synthetic estradiol:
Numerous studies have ben published showing the efficacy of limiting the decline in estrogen to less than 20 mcg by adding back estrogen during menstruation or using continuous oral contraceptives to prevent menstruation and avoid MRM.
Hormonal therapies aimed at preventing MRM include:
• Adding back estrogen with an estradiol patch during a woman’s natural menstrual cycle
• Taking continuous estrogen-containing oral contraceptive (birth control) pills for three months then cycling off for menses and repeating (4 periods per year) or taking estrogen-containing oral contraceptive pills for an entire year before cycling off to allow for menses
• Adding an estradiol patch during menstruation during the placebo week when on oral contraception with estrogen-containing pills to prevent the precipitous decline in estrogen that week that would induce a migraine
“There are some counter indications to the use of hormone-based interventions,” warns Autry. “The use of estrogen-progestin contraceptives in women who have migraines with aura can be problematic, since these patients are at an increased risk of stoke. Therefore this type of contraceptive should be used with caution. It is also suggested that for most adolescents with menstrual migraine the use of estrogen-progestin contraceptives should be delayed until two years after their first period.”
“Menopausal women who experience migraines due to a decline in estrogen,” adds Autry, “have achieved significant benefit in low dosage estrogen replacement therapy if no other risk factors are present.”
Treppendahl and Autry both stress the importance for any woman who believes she is experiencing Menstrually Related Migraines, to discuss her symptoms with her health care provider.
“There is no need to suffer each month when therapy is available,” concludes Autry.
Mickie Griffith-Autry, PhD, NP-C, earned her Bachelor of Science degree in nursing from Jacksonville State University, her Master of Science degree in nursing from the University of Alabama Huntsville, and her PhD from Walden University. Her research dissertation was entitled Pelvic muscle strengthening: Impact on sexual functioning in the menopausal woman. Ms. Autry sees patients at Ovation Women’s Wellness at 4814 Lakeland Drive in Flowood.
Christina Treppendahl, RN, MSM, FNP-BC, is founder and director of The Headache Center at 1000 Highland Colony Parkway, Suite 7205 in Ridgeland, MS. Treppendahl is a Family Nurse Practitioner with a Master of Science degree in Neonatal Nursing from Vanderbilt University and a Post-Master’s degree in Family Nursing from The W in Columbus, Mississippi. She is certified in headache medicine by the National Headache Foundation.
Ms. Treppendahl is a national speaker for migraine-specific FDA-approved pharmacologic therapies and has given presentations for the National Headache Foundation and the American Academy of Nurse Practitioners.