When I talk with patients, I often describe managing migraine pain as if we’re nurturing an orchid. These flowers are beautiful but delicate. They prefer a consistent environment to thrive and grow. That’s why I advise patients with migraine to treat themselves like an orchid: Build routines of self-care that work for you and stick with them.
This often means education around the four key lifestyle factors associated with migraine:
- Hydration: Studies have shown that drinking more water, around 7-8 glasses per day, can help reduce headache severity, frequency, and duration.
- Nutrition: Avoid skipping meals to stay consistent.
- Sleep: Establish a regular schedule and a comfortable environment to maximize the benefits of a good night’s sleep.
- Stress: Managing your stress with techniques like relaxation, meditation, and physical exercise can help manage headache.
If we can optimize those factors, we can keep the brain happier and make it less likely to kick off another debilitating headache attack.
But humans aren’t orchids. Our bodies aren’t that stable. Women are three times as likely as men to have migraines, in large part because of hormone fluctuations during the menstrual cycle and throughout life.
The hormonal changes associated with menstruation mean that many women with migraine aren’t getting the complete diagnosis and the best treatment.
At UNM Health Sciences Center Department of Neurology, we see patients with all types of migraine. Advances in treatment mean we can help many patients find relief from the debilitating symptoms of menstrual migraine.
That's the spirit of what I want our trainees to learn: While our bodies strive to achieve stability, we need to remember that we are actually transitory organisms, and we change all the time.
What is menstrual migraine?
The symptoms of menstrual migraine are the same as regular migraine:
- Throbbing or pulsating pain on one side of the head
- Sensitivity to lights, sounds, or smells
- Nausea, vomiting, and loss of appetite
- Dizziness and fatigue
What’s different about menstrual migraine is when it occurs. Strictly defined, menstrual migraine is “attacks that occur between two days prior to menses up to three days after it starts at least 66% of the time.”
From there, we classify it further based on when the attacks occur in relation to the menstrual cycle:
- Pure menstrual migraine means the attacks happen only in association with menses.
- Menstrually-related migraine means the patient experiences attacks at any time, but the symptoms worsen significantly during the menstrual period.
- End-menstrual migraine that begins several days after bleeding begins is due to transient iron deficiency, not directly related to hormonal changes.
Research shows that menstrual-related attacks are often more severe and last longer than attacks during other times of the month. In fact, studies have found that menstrual migraine attacks can last for up to 35% longer than those unrelated to the menstrual cycle.
Why does menstrual migraine happen?
For the most part, the reason for menstrual migraine is estrogen. We know that before menstruation, levels of estrogen in the body drop quickly. Estrogen functions as a painkiller and a mechanism for regulating blood vessels. When estrogen levels drop suddenly, pain receptors become more sensitive and blood vessels dilate. This combination was believed to be the primary cause of migraine pain.
For a long time, the medical community was satisfied with that answer. Then we started to realize that some people with menstrually-related migraine feel worse during and after their period – but not before. It turns out, those symptoms are often related to iron deficiency rather than estrogen levels. Many patients in our clinic find that supplementing their iron intake offers a significant improvement.
Similar variations in symptoms happen with women as they reach perimenopause and menopause. No more periods mean estrogen levels stabilize, which should mean that menstrual migraine is no longer a problem for older women. For some patients, that’s the case, but there’s a subset of women for whom menopause unfortunately makes their attacks worse.
Related reading: Functional Neurological Disorders: Giving ‘Invisible’ Conditions a Name
What else do we need to consider?
Much of the research on headaches and hormones assumes patients have regular menstrual cycles and can track the onset and intensity of their symptoms. While this data underlies our basic treatment protocols, the research doesn’t fully address the needs of those with irregular periods and unpredictable symptoms.
Because estrogen level is a significant factor in menstrual migraine, some women can benefit from taking a hormonal contraceptive to keep their levels steady. To achieve this, patients must be specifically instructed to skip the “placebo” pills each month or replace their vaginal ring immediately without the seven-day wait indicated in the manufacturer’s directions.
However, we also need to be aware of the type of migraine attack the patient experiences. Most menstrual migraine attacks occur without aura. However, the few women who experience migraine with aura have a higher risk of stroke and blood clots. Estrogen levels are also a significant risk factor for these complications, making estrogen-based birth control a controversial topic in the field.
To understand all the variables at play, it’s important for patients and doctors to communicate openly and honestly, without stigma. Sometimes, that means working together with their gynecologist or a vascular specialist to develop the best treatment plan.
How is menstrual migraine treated?
For most patients, the treatment plan will include:
- A daily preventative medication, often a newer intervention like a gepant or a CGRP antagonist injection
- A rescue mediation such as a triptan during their menstrual cycle
- An antiemetic to control nausea.
These effective new medications work in new ways, and they’re offering more patients real relief than ever before.
We also look at our patients’ vitamin and mineral levels. For instance, we know that the cerebrospinal fluid of people with migraine is . Research shows magnesium can increase the effects of oxytocin and stabilize other hormones. I nearly always recommend magnesium to my patients right away—especially those with menstrual migraine.
Related reading: Migraine and Chronic Headache: New Attitudes—and Real, Effective Treatments
Overcome the stigma of hormonal headaches.
At the UNM Health Sciences Center Department of Neurology, our patients have often already seen many doctors and tried many remedies, most often without success.
In some cases, they have atypical or unpredictable symptoms, and report that they feel crazy and alone. I’m able to reassure them that these feelings are normal, and most of my patients feel exactly the same way.
Many patients are familiar with being dismissed or told they’re whining, but this may stem from our own feelings of paralysis or inadequacy as providers from a time when the options really were quite limited.
It’s important for people with any type of migraine – but especially menstrual migraine – to know that headache care is different, and better, than ever before. There are more effective treatments, and we’re proud to offer hope for fewer migraines to patients who have spent years in pain.
What is a career in headache medicine really like?
I tell all our trainees it’s a rare delight in medicine to be fairly confident you’re going to be able to help a patient.
Not only is migraine treatable, it’s also a fascinating tour of all the conditions that we see in every subspecialty of neurology. Almost any episodic brain dysfunction can be caused by migraine, and this specialty empowers you over to make a difference in so many otherwise difficult symptoms.
It’s life-changing for most of your patients that you exist, and it’s so rewarding to be able to help.
Neurology Care
To find out whether you or a loved one might benefit from neurology care, call 505-272-4866.