How To Prevent Menstrual Migraines

Menstruation can be tough on its own. Alongside the typical symptoms posed during a menstrual cycle, migraine attacks can also be a common occurrence which can happen every month around the time of menstrual bleeding.  In fact, more than half of women who experience migraines have spotted a link between their period cycles and these migraine attacks.

A menstrual cycle is orchestrated by hormones. During a period, there are multiple hormones slowly making their way around your body, with both rising or falling levels depending on where you are in the cycle. This fluctuation has major effects on a woman's body, including migraines.  As these hormonal based headaches can appear a few days before, or early during your period, knowing how to combat these headaches could make all the difference in either reducing, or preventing them entirely. 

Preventing these types of headaches requires self care, alongside the help of medication to help relieve the pain or prevent the headache entirely. 

What are menstrual migraines?

 Migraines are a type of headache that causes a throbbing pain, typically on one side of the head, with or without aura. Unlike other types of headaches, Migraines can occur at any time due to various triggers. However, menstrual migraines are migraines which manifest alongside your period. One in five women will experience migraines at some point, and almost two in three women experience migraine attacks during the start of their period.^1,2 These attacks are attributed to the decline of estrogen levels at the start of menstruation, which occurs two days before or up to three days after menstrual bleeding.²

Menstrual migraines typically occur during the early stages of a period and can last from a few hours to a few days. These attacks can be subdivided into two categories:

• Menstrually related migraines: This refers to experiencing migraines during other times of the month in addition to the beginning of your period. This is the more common form

• Pure menstrual migraines: This is when migraines occur exclusively during the beginning of menstruation and is thought to affect fewer than one in ten women

It is important to remember that while migraine and menstrual migraines can be painful and debilitating, they are common and do not pose a threat to your overall health. 

What causes menstrual migraines?

The primary cause of menstrual migraine is hormone fluctuation. Hormones are chemicals which act as messengers within the body and cause a response. 

In this case, sex hormones such as estrogen and progesterone are involved in the mid to late stages of your period. During the luteal phase, the last phase before menstruation, these hormones fluctuate as part of a natural change in hormone levels. Whilst this aids in the reproductive cycle, it can also have a role in causing migraines. 

Estrogen withdrawal 

Estrogen is a hormone which plays a major role during the menstrual cycle. It releases the egg during ovulation and causes the thickening of the uterine lining during pregnancy. If pregnancy is not achieved, estrogen levels fall and menstrual bleeding begins. 

Estrogen withdrawal refers to the fall of estrogen levels that happens at the end of each cycle. The effects of a deceased level of estrogens have been identified to modulate brain cell inflammatory responses and cause blood vessel dilation, thus triggering migraine attacks.  

Some forms of hormone contraceptive methods, including the birth control pill, have been identified to potentially worsen these hormonal headaches. This occurs when there is a break, known as a hormone-free interval after the three-week period of taking the medication which causes a drop in estrogen levels. 

Progesterone withdrawal

Progesterone is a steroid hormone produced mainly within the ovaries and a small amount is released from the adrenal glands. Progesterone levels drop at the end of a period cycle. Research shows an increase in progesterone levels in women experiencing migraines with an aura. 

What triggers migraines in women?

Hormone fluctuation and migraines are closely linked. Around 75% of women who suffer from migraines, noted migraine attacks just before the start of the period, or early during the period cycle.¹ However, there is a multitude of other triggers that can cause migraines in women. These can include:

Emotional Triggers: including tress, epression, hock, ension.

Physical Triggers: including excessive tiredness, irregular sleep patterns (too much/too little sleep, shift work), poor quality sleep, poor posture, tension, and ver-exertion during exercise . 

Environmental Triggers: eather changes (barometric pressure changes, humidity and heat which cause dehydration),  light (flickering, natural/unnatural light sources, bright lights), and loud sounds.

Dietary Triggers: cheese, cChocolate, foods with additives, baked goods containing yeast, soy products, tomatoes, and some fruits and fruit juices.

What are the symptoms of a menstrual migraine?

A migraine attack linked to the end of a period cycle is a key symptom of menstrual migraine. People suffering from hormonal headache, may experience symptoms including:

• Nausea
• Vomiting
• Throbbing headache
• Without aura or aura prior to migraine onset
• Heightened light or sound sensitivity

Premenstrual Syndrome (PMS) headaches can also include other symptoms such as; acne, bloating, fatigue, joint pain, breast tenderness, cravings, constipation, decreased urination, lack of coordination, and mood changes. 

Relationship between hormones and headaches?

As mentioned, falling estrogen levels before a period are the main cause of hormonal migraines due to their effects on blood vessel dilation and blood pressure. Estrogen has also been shown to impact brain cell (neuronal) excitability by affecting other hormones, such as serotonin, which also interacts with blood vessels in the brain.  

Research has also described a close relationship between hormones and headaches, mainly due to their effects on neuroinflammation. Neuroinflammation is a process where proteins (vasoactive proteins and proinflammatory cytokines) are released within the brain. This causes inflammation of the brain tissue, which stimulates brain cells and causes the sensation of pain.^3,4 

Difference between menstrual migraines and other types of migraines?

Whilst migraine and menstrual migraines have similar symptoms, typical migraines can be caused by a multitude of different triggers.  Menstrual migraines are caused primarily by a drop in estrogen. The  three main differences between migraines and menstrual migraines are:

1. Theyast longer than normal migraines
2. The pain is more ore severe
3. They are less responsive to treatment

Who is more likely to get a menstrual migraine?

Menstrual migraines can affect any woman who is experiencing her period, meaning that female children to adults (pre-menopausal) are more likely to suffer from this form of headache. In addition to this, these hormone-based headaches can also occur during:

Pregnancy During the first trimester of pregnancy, estrogen levels can quickly rise before decreasing again. As previously mentioned, this fluctuation is a common trigger for hormone headaches. Furthermore, an increase in blood volume during this early stage of pregnancy can also cause additional pressure on brain nerve cells which can trigger pain. Typically, hormones stabilise after the first trimester, with research identifying a 30% decrease in migraine frequency during the second and third trimesters of pregnancy.⁵
Taking medications for migraines can affect a baby, and therefore should be avoided unless specified otherwise bythe healthcare provider.

Post pregnancy, a quick drop in estrogen levels alongside any stress, irregularities in sleep or eating patterns may also cause headaches. Speak to your medical professional before continuing medications, particularly if breastfeeding.

• Perimenopause and menopause
  During perimenopause, fluctuations occurring between longer periods of estrogen withdrawal are also believed to contribute to migraines, with research identifying a higher frequency and intensity of migraine headaches during this time.⁶  These symptoms than typically improve during menopause. However, tension headaches have also been identified to often become worse. Speak to a healthcare provider to explore medications or hormonal replacements if headaches persist during this time 

Those taking combined oral contraceptive medication
Women taking a combined oral contraceptive pill, have also noted an increase in migraine attacks during a pill-free week. As many types of birth control pills contain estrogen, estrogen levels drop rapidly, causing migraines. 

How are menstrual migraines treated? 

There is a multitude of options available to people who suffer from menstrual migraines, from self-care to prescription medicine. It is important to first understand whether your migraine headaches are triggered as a consequence of your period, and a doctor may ask for you to start by keeping a headache diary. Noting this information can pinpoint any patterns which may connect your periods and migraine onset, or determine any other triggers which may be contributing to the headache.

In the meantime, self-care options you can try include: 

• Avoiding stress
• Drinking plenty of water.
• Regulating your sleeping patterns
• Avoiding alcohol and smoking
• Eating regularly to keep up blood sugar levels 
• Reducing screen time
• Staying active
• Over-the-counter medications, such as paracetamol or ibuprofen

If you are experiencing a migraine, and are struggling to find relief, there are other options which may help alleviate some of your symptoms. These include:

• Resting in a quiet, dark room
• Using a cold or warm compress
• Deep breathing exercises

What medicines can I use?

As previously mentioned, taking over-the-counter pain relief medications such as paracetamol, or ibuprofen (taken according to the manufactures dosage guidelines) may offer some relief. In some cases, migraine attacks require prescribed medication instead. A medical professional may look into acute treatment options including the prescribing of anti-inflammatory medications (NSAIDs), triptans or dihydroergotamine. 

Preventative medication

Treatment options for migraine headaches can also include long-term preventative medicines, to try to stop the migraine before it even manifests. Such can include;

• Beta-blockers (reduce blood pressure)
• NSAIDs such as naproxen 
• Triptans such as frovatriptan, naratriptan, sumatriptan or methylergonovine
• Dihydroergotamine or DHE (nasal spray or injection)
• Magnesium 
• CGRP receptor antagonists

Hormone replacement therapy

In cases where preventative treatment is unsuccessful, the use of hormone therapy may be offered. This involves the prescription of estrogen supplements (such as Estradiol) to increase your body's estrogen levels. This is typically used in menopausal hormone therapy, and can also aid in treating other symptoms of menopause, such as sweats and hot flushes.

It is recommended to use patches or gels in this form of treatment to ensure hormonal stability.   

Continuous contraception 

Taking oral contraceptives continuously can ensure consistent hormone levels within your body. Consecutively taking the combination pill, without a break, avoids fluctuations in estrogen level. This minimisation of estrogen withdrawal may improve the severity and frequency of period headaches. Other tips can include; 

• Elimination or minimisation of placebo or inactive days
• Using birth control pills with a lower dose of estrogen
• Using NSAIDs and/or triptans during placebo days
• If experiencing migraines with auras, avoid hormonal contraception containing estrogen, this can be replaced with progesterone-only birth control, also known as the mini pill

How long will I have menstrual migraines?

Menstrual migraine may end when you stop menstruating and your hormones have stabilised. This may mean that you stop experiencing this type of migraine headache during orafter the menopause.  

When should I contact my healthcare provider? 

If over-the-counter medication and self-care are ineffective at relieving your pain, then you should contact your healthcare provider. From here you can discuss the best available treatment options.  Visit your doctor if: 

• There is an increased severity of migraine or change in headache pattern
• Medication is unsuccessful at alleviating pain

Summary

Menstruation can be a difficult period of time during the month, and the inclusion of migraines can make the situation worse. If you are experiencing menstrual migraines and are unable to effectively manage them, then visiting your healthcare provider to explore preventative solutions can help alleviate your symptoms.