Menstrual migraine: update on pathophysiology and approach to therapy and management

Menstrual migraine (MM) is often reported to be more severe and more resistant to treatment than other migraines. Nevertheless, initial treatment should be the same as for any migraine. When results of acute therapy are incomplete or unsatisfactory, preventive strategies are warranted, including both pharmacologic preventives and careful adherence to lifestyle modifications. Where MM differs from other attacks is in its predictable timing and discrete precipitants. These differences allow for unique preventive strategies that target either the timing of the attacks or their hormonal precipitants. Nonspecific MM strategies-those that do not address the hormonal mechanism-include scheduled dosing of nonsteroidal anti-inflammatory drugs (NSAIDs) or triptans throughout the menstrual window. NSAIDs are a good choice when there is comorbid dysmenorrhea and allow for treatment of breakthrough headaches with triptans. Both strategies require that the timing of MM is highly predictable. Specific strategies for MM are those that reduce or eliminate the premenstrual decline in estradiol that predictably precipitates attacks. These include continuous or extended-cycle dosing of combined hormonal contraceptives (CHCs). A number of common gynecologic comorbidities argue for early adoption of these treatments, as CHCs effectively treat dysmenorrhea, menorrhagia, ovarian cysts, endometriosis, and irregular cycles. In the author's experience, hormonal preventives are the best approach for most women whose menstrual attacks are resistant to acute therapy. They afford the greatest therapeutic benefit in prevention while treating common comorbidities and allowing for acute treatment with triptans when needed.