Menstrually related migraine: breaking the cycle in your clinical practice

The purpose of this review is to provide a simple, evidence-based approach to the diagnosis and treatment of migraine. The review is based on clinical experience data, results from placebo-controlled trials and pharmacokinetic information of clinical importance and is a distillation of material from a comprehensive literature review of the epidemiology, pathophysiology, diagnostic features and treatment of menstrual migraine. Migraine, particularly menstrual migraine, is most prevalent in women of childbearing age. Menstrual migraine is generally severe, lasts longer, recurs more frequently, results in greater disability and is more resistant to therapy than nonmenstrual migraine. Despite the associated disability for otherwise-healthy women, migraine is frequently not diagnosed. The initial visit to an obstetrician/gynecologist is an ideal time to screen women for menstrual migraine. Triptans are effective in the acute treatment of menstrual migraine. Naratriptan and frovatriptan also have been evaluated for prophylactic efficacy. Both agents were effective in reducing the incidence of menstrual migraine. Frovatriptan also reduced the severity and duration of breakthrough headaches. Acute treatment is typically the same for menstrual and nonmenstrual migraine, involving the use of nonsteroidal antiinflammatory agents (NSAIDs), triptans or, rarely, ergot derivatives. In addition, NSAIDs, magnesium supplementation, estrogen therapy and triptans have been proven effective for short-term prevention of menstrual migraine. In some patients, continuous estrogen therapy may be necessary to control these headaches. Improved diagnosis and treatment of menstrual migraine is critical to decrease the associated disability. Acute and shortterm preventive therapy with triptans is effective; oral contraceptives may be used for long-term preventive therapy.