Attacks of migraine during menses are called menstrual migraine. These attacks have been found to be more refractory to treatment. They are reported as more severe and disabling headaches than those headaches that are not associated with menses.
A decline of estrogen is believed to be the trigger of menstrually related migraine. This happens during the natural menstrual cycle and during the placebo week for women taking birth control pills containing forms of estrogen.
Fortunately, new approaches and therapies have emerged in recent years for the management of menstrual migraine that resists conventional treatment.
Short-term prophylactic therapies aimed at preventing menstrual migraine are initiated a few days before the start of the anticipated menstrual migraine. Naproxen sodium 550 mg twice daily has demonstrated effectiveness when given several days before menses and continued throughout the menstrual cycle.
Three tripans, frovatriptan (Frova), naratriptan (Amerge) and zolmiptripan (Zomig) administered BID or TID during the peri-menstrual time period have also demonstrated effectiveness.
Vitamin E (400 IU daily) given as a short term prophylactic was superior to placebo in decreasing pain severity and functional disability in women with menstrual migraine in a placebo-controlled double-blinded trial.
For women without contraindications for oral contraception with estrogen containing hormone pills, another prophylactic therapy with proven efficacy is aimed at avoiding the decline in estrogen and thus, avoiding the menses all together by omitting the placebo week of pills.
There are also combined oral contraceptives on the market that do not contain a placebo week which keeps a stable dose of estrogen on board and eliminates bleeding. The continuous estrogen without a placebo week has also been effective with a vaginal ring known as NuvaRing. Instead of replacing the Nuvaring every 4 weeks, the woman is instructed to change it every three weeks.
For those women not taking birth control pills, transdermal estradiol patches used during the peri-menstrual period have also demonstrated efficacy in menstrual migraine prevention.