Menstrual migraine affects over 50% of women (1). Of these woman, most will experience migraine during menses but also at other times of the month. Migraine during menses tend to be a more severe, harder to treat and often reoccur even despite medications.
Unfortunately, many women have resigned to menstrual migraine because if there's little you can do about your cycle then there is not much you can do about your migraine attacks. Right?
There a number of options to treat and prevent, yes, prevent menstrual migraine attacks. To understand how and why these treatments can help, it is worth understanding what’s going on during the month.
How The Menstrual Cycle Causes Migraine Attacks
Women who have a tendency to get menstrual migraine are those who are sensitive to hormonal fluctuations experienced just prior to the onset of menstruation. Just before menstruation there is a natural drop in progesterone levels.
The two important females hormones involved are progesterone and estrogen.
Progesterone is a natural steroid hormone involved in the female menstrual cycle that stimulates the uterus to prepare for pregnancy. It is a naturally occurring hormone in the female body that helps a female function as normal.
Estrogens or oestrogens (American and British English spelling respectively), are a group of compounds which are important in the menstrual and reproductive cycles. They are also naturally occurring steroid hormones in women that promote the development and maintenance of female characteristics of the body.
It is important to note that estrogens are used as part of some oral contraceptives and in estrogen replacement therapy for some postmenopausal women.
Throughout the natural menstrual cycle the levels of these hormones fluctuate. During the cycle, the levels of progesterone and estrogens also change in relation to each other. See the image below for how these levels change throughout the cycle.
This occurs as part of being a healthy fertile woman. Women with menstrual migraine attacks may be sensitive to the changes in their estrogen level relative to progesterone.
If this balance is slightly off for what your body requires, then you may have uncomfortable physical symptoms such as PMS, breast tenderness, headaches and, in susceptible women, migraine attacks.
Timing Is Important For Treatment
Timing is important because it can impact how best to treat each case of menstrual migraine. Below are different hormonal states that may be causing your regular menstrual migraine.
- If it occurs just prior to the onset of menstruation then it may be due to the natural drop in progesterone levels.
- Headaches and migraine attacks can also occur at ovulation, when estrogen and other hormones peak.
- Or it may occur during menstruation itself when estrogen and progesterone are at their lowest.
Knowing when your menstrual migraine occurs will determine the best prevention strategy. A good way to determine when your migraines are occurring is by keeping a record of at least 3 cycles to track exactly when your migraines occuried. Remember to note the precise day(s) of your cycle.
Once you have a clear understanding of which days in your menstrual cycle the migraine is occurring, then you are in a good position to begin treating it.
Menstrual Migraine Treatments
There are many different approaches to help manage menstrual migraine some involve medicinal treatments and others do not. Often it may involve a combination.
Rest assure that it is possible to reduce and in some cases eliminate menstrual migraine. But it may involve some effort, knowledge and working with a specialist.
Common treatments for those with menstrual migraine include:
- Dietary changes
- Lifestyle factors
- Hormonal balancing
- Preventative migraine treatments
- Acute migraine treatments
- Natural & homeopathic therapies
If there is an imbalance of estrogen in relation to progesterone then a healthy diet is the first step (in fact it should be one of the first steps for all migraine patients). What we eat, plays a huge role in your overall health and wellbeing.
If you experience migraine attacks then you diet becomes especially important.
We hear all the time from the health community something like ‘eat a varied and well balanced diet to help prevent disease’. But it's been said so many times we can become numb to this important advice.
To complicate things, some otherwise healthy foods may also act as trigger foods. Finding out which foods trigger attacks can be difficult.
1) Dietary Changes: Why Is Diet Important For Menstrual Migraine?
Estrogen levels require stricter regulation compared to other hormones in your body to ensure the natural rhythm runs smoothly (2).
Small variances above or below the normal regulated levels can have significant impacts on your health.
The liver metabolizes estrogen. A healthy liver will rapidly metabolize estrogen but if it is overloaded with medications, artificial substances, chemicals or harmful substances from food or drink it can affect the metabolisation of estrogen.
Our diet is thought to be the biggest factor affecting our hormones through the exposure to certain chemicals in food products. Research suggests that diet can attribute up to 90% of all factors affecting your hormones (3).
Certain food ingredients act like toxins which can disrupt your hormonal balance, so reducing or eliminating these help keep your hormones in balance. Examples of toxins you may commonly come across include:
- MSG (monosodium glutamate) - found as a flavor enhancer in many processed foods.
- Hydrolysed Vegetable Protein
Avoid or, if possible, eliminate
- simple carbohydrates
- refined sugars
- processed foods
- and avoid of well known migraine trigger foods.
If in doubt about what food triggers your attacks, it may be worth considering some of the following:
- keep a food diary
- food allergy test
- an elimination diet
- consult a certified dietitian or nutritionist
Keeping a food diary is highly recommended. Be careful to include in your diary not just what you eat, but also record other factors which affect your migraine attacks to minimise misattribution of a migraine attack to a particular food or trigger. Uncovering what exactly caused the attack takes a little time and patience but the process gives you much more control over your condition. The results are often surprising.
Food allergy tests unfortunately do not test for specific migraine triggers. But they can be effective at showing what foods your body is reacting abnormally too. Eliminating foods which cause stress or over reactions in the body may improve your migraine frequency or severity.
A detoxification may help cleanse your system of the offending substances but there is little scientific evidence supporting the efficacy of a detoxification. It may simply be a psychological way to push the 'restart' button when beginning a new eating regime.
If you are serious, consulting a certified health care professional like a nutritionist or dietitian to assist you is a good idea. Elimination diets can be tricky and sometimes dangerous to do by yourself. There is a risk of malnutrition if you don’t know exactly what you’re doing.
To ensure your wellbeing seek qualified professional support. That way you will have the best chance of reducing your attacks without malnourishment or starvation.
Another simple dietary preventative includes getting enough hydration, especially during menses.
2) Lifestyle Factors
Lifestyle factors like sleep and exercise play a central role in migraine management and sustainable remission.
The right levels of sleep and exercise are VITAL.
Sleep is a restorative function for brain and body. And it is not just about getting enough sleep each night. It’s about how regular your sleep/wake cycle is. Are you going to bed and waking up at the same time each night? What about on weekends?
It's also about the quality of sleep. The hours of sleep before midnight count more. 9 hours total sleep starting from 10pm is much better than 10 hours of sleep starting from 1am.
Are you waking up at the same time each morning?
Nobody is perfect, but the better you can get into a consistent routine of high quality sleep, the better for your condition.
Exercise promotes a healthy metabolism, hormonal balance, reduces stress, assists in sleep, stabilizes your mood and gives you an overall sense of well-being.
Just in case you needed another reason, the brain loves exercise. Exercise is a great preventative tool for many with migraine and the science is proving it. One study showed  that exercising using the indoor bike for a 20 min workout 3 times per week was as effective as one of the most popular migraine preventatives - topiramate.
For a few people exercise can trigger migraine attacks. If that's the case, start slowly and build gradually. Give yourself a generous and slow warm-up before jumping into your exercise. Be sensible about it. Don't start by trying to run 5 miles. Don't exercise on days when your feeling vulnerable to a migraine attack.
If you exercise outside, wear a hat, keep hydrated and don't let yourself get too hungry.
The evidence for daily exercise is building. Starting small can be a 5 min walk or a short, easy bike ride.
You will feel better for it. When you take care of the body, the body is more likely to take care of you.
3) Hormone Balancing
Addressing hormones without addressing underlying diet and lifestyle factors is like trying to clean the house by sweeping all the dirt under the rug. It's a superficial approach.
Hormones do have a significant influence on bodily functions. 80% of pregnant women experience a remission of migraine during pregnancy according to studies. 
To assess hormone levels, blood, saliva and urine testing may be performed to establish a baseline and to identify any hormonal imbalances which may be contributing to migraines.
Thyroid testing is also important as hypothyroidism is more common in those with migraine.
Commonly the key trigger is the falling levels of estrogen which occurs naturally before menses. Estrogen can be topped up in several ways such as via skin patches or gel which is absorbed into the bloodstream. A patch can be applied for 7 days beginning 3 days prior to the first day of menses. Note: if you are trying to get pregnant you should speak to your physician before you explore hormonal treatments.
Another increasingly popular approach to deal with the drop of estrogen involves stabilising hormones through the use of the low dose estrogen combination pill which has a constant dose (monophasic).
For others, problems appear to arise due to the estrogen dominance and progesterone deficiency. In these cases, bio-identical progesterone in the second half of the female cycle to balance the hormones has shown some success (4).
It is a good idea to consult with a healthcare professional who has experience with menstrual migraine and who understands female hormones. Look for a headache specialist, certified gynaecologist or endocrinologist who has a track record with menstrual migraine.
4) Preventative Menstrual Migraine Treatment
Preventative treatments can be both medicinal and non medicinal.
Research suggests that magnesium supplementation for those with menstrual migraine can be beneficial. It has also found that low magnesium levels may be attributed to an lower migraine threshold. Lower migraine thresholds make you more vulnerable to attacks and require less stimulation and fewer triggers to lead to an attack.
400mg of magnesium everyday can be used as a migraine preventative. Unfortunately there no simple tests for magnesium deficiency as it's the intracellular level of magnesium that we need to improve. The best way to see if it works for you is to try it and ensure that you are absorbing it effectively.
If the migraine attacks are severe or also occur frequently outside of menses then a migraine preventative may be prescribed.
When considering preventative medicinal treatments it is best to discuss what options might be best for you with your doctor who has your full medical history. Read more about the different preventative treatments for migraine here >>
5) Acute Migraine Treatment
Often those with menstrual migraine may develop a mini prophylaxis strategy with their doctor where they may take treatments like NSAIDs (non steroidal anti inflammatory) such as iburopofen, naproxen (eg. Aleve), mefenamic acid during the key phase of the cycle to help prevent attacks.
500mg of naproxen once or twice daily has been shown to be effective around the time of menstruation. Patients may be advised to begin the dose a few days before the anticipated menstrual migraine.
Mefenamic acid can be effective for those with heavy or painful periods. 500mg of mefenamic acid can be taken 3-4 times daily.
Others may use a low dose of a triptan such as frovatriptan, sumatriptan or naratriptan.
If used only around the time of menses then the risk of developing medication overuse headaches is low. NSAIDs and triptans are most likely to be effective as mini-preventative treatments if started 24-48 hours before the expect onset of menstrual migraine.
6) Natural & Homeopathic Therapies
Whilst there is less clinical evidence behind the efficacy of natural and homeopathic therapies, they may have less side effects, be better tolerated and offer a natural alternative.
That said, if they don’t help, you’ve wasted your money.
Do your research before jumping into these kind of treatments to decide if it’s appropriate. For a listing of over a dozen alternative therapies click here >>
If you don’t have a well-balanced diet then you may not be getting your required vitamins and minerals. Supplements in this scenario may be useful. Some that have been reported to help those with migraine include: Riboflavin, Feverfew, Butterbur, Vitamin B6, Magnesium, Ginger, Coenzyme Q10 (CoQ10) amongst others.
Ordering the cheapest option from Amazon is not your best option. Vitamins are still considered medication but have far less regulation and quality controls in place. Often it's worth paying extra for a reputable brand to ensure quality and safety.
Many vitamins are contra indicated for pregnant woman or woman trying to get pregnant so speak to your pharmacist or doctor before ordering them.
Watchout: Hysterectomy For Menstrual Migraine
Should you get a hysterectomy if you're past the child bearing years and you're sick of your migraine attacks?
The short answer is definitely no.
There is strong evidence supporting a hysterectomy for migraine. A hysterectomy purely for menstrual migraine is permanent, invasive, unproven and an expensive surgical operation.
Why is it ineffective for menstrual migraine?
Menstrual migraine attacks are caused by a fall in hormones which is trigged by the ovaries. Whilst menstruation stops with a hysterectomy, it does not stop the ovaries from continuing to trigger monthly hormonal fluctuations.
There are other ways to non-surgically address the hormonal fluctuations caused by the ovaries. See hormonal treatments listed above.
Reducing Your Menstrual Migraine Attacks
To summarise, if your migraine attacks occur at the same time each month:
- Keep a diary to inform you and your healthcare professional of exactly when the attacks begin during your cycle.
- Address your diet first
- Get enough quality sleep, consistently
- Exercise regularly
- Stay adequately hydrated, especially during menses
- Try magnesium supplementation
- Balance your hormones
- If severe, consider preventative migraine treatments
- Consider NSAIDs or a low dose triptan during menses
- Consider natural and homeopathic remedies and supplements known to help those with migraine.
Often, it is the things we consume or do unknowingly that exacerbate migraine. Identifying and modifying these factors with an improvement to your lifestyle and diet is where you can have the most dramatic and sustainable results.
Are you struggling with menstrual migraine? Let me know in the comments below.
Need something simple for your hormonal migraine attacks?
- MacGregor E.A., Brandes J., Eikermann A., Giammarco R. (2004) Impact of migraine on patients and their families: the migraine and zolmitriptan evaluation (MAZE) survey-phase III. Curr Med Res Opin 20: 1143–1150
- Holmes, M NP, http://www.womenshealthnetwork.com/womenshealth/menstrualmigraines.aspx Accessed Oct 2013.
- Fürst P (October 2006). "Dioxins, polychlorinated biphenyls and other organohalogen compounds in human milk. Levels, correlations, trends and exposure through breastfeeding". Mol Nutr Food Res 50 (10): 922–33.
- Mostovoy, A. ‘Migraines – Helpful Solutions’ http://www.drmostovoy.com/Migraines.htm. Accessed Oct 15, 2013
- Varkey, Emma, et al. "Exercise as migraine prophylaxis: a randomized study using relaxation and topiramate as controls." Cephalalgia 31.14 (2011): 1428-1438.
- Somerville, Brian W. "The role of estradiol withdrawal in the etiology of menstrual migraine." Neurology 22.4 (1972): 355-355.