Migraine doesn’t discriminate by gender. In fact, until puberty, migraine is equally prevalent in both sexes. Once puberty strikes, however, migraine incidence dramatically increases in girls for one simple reason—hormones.
During puberty, estrogen and progesterone levels rise in girls. When menses begins, these hormones start cycling from low levels just before a period to high levels afterward. This is a critical time in the development of migraine because fluctuations in estrogen levels are believed to be one of the biggest triggers of migraine headaches.
For many girls and women, headaches are closely tied to the menstrual cycle. In particular, migraines are more likely to occur shortly before or during periods—a condition called menstrual migraine.
Recently, we at the Cleveland Clinic asked 75 female patients aged 10 to 20 years to fill out a questionnaire so we could better understand the effects of menstrual migraine. More than half (55%) reported they “definitely did not” have headaches before the onset of their periods, while only 8% said they “definitely did.” For 33% of women surveyed, headaches usually worsened around the time of their periods.
Diagnosing menstrual migraine is generally simple if headaches only occur during a small window of the month: from two days before menstruation to the third day of menstruation. This is called pure menstrual migraine. But sometimes women have attacks at other times of the month in addition to recurrent migraines around their period. This subtype, called menstrually related migraine, is more common in mature women than in teenagers.
It also makes diagnosis more complex. For example, 15-year-old Emily* was referred to our clinic with a history of constant headaches. She had both a chronic daily low-level headache, which began when she was 8 years old, and a more intense one-sided headache that occurred approximately once a month and was accompanied by nausea, light and noise sensitivity, and light-headedness.
We asked Emily to keep a headache diary for three months to help us pinpoint patterns and connections. During that time, she recorded information about all of her headaches and periods. When we reviewed the diary, we were able to see a link between her severe headaches and her menstrual cycle. I recommend that all young women with headaches keep a diary for three months as Emily did.
Menstrual migraine is treated the same as other migraines—with nonsteroidal anti-inflammatories (NSAID), triptans or sedatives. If the headache generally lasts more than two days and periods are regular, short-term prevention may be considered. Although the Food and Drug Administration has not approved any treatment for the prevention of menstrual migraine, a number of medications have proven to be effective when taken for two to three days prior to menstruation and for the first two days of menstruation. These include the NSAID naproxen, the long-acting triptans Frova® and Amerge®, and magnesium supplements. Using oral birth control pills to modify menstrual migraine is generally not recommended as the initial approach.
Migraines that fall around menses are often more severe than those that strike at other times of the month. But here’s the good news: Because these headaches are predictable, they can be planned for with acute or preventive treatments. Maintaining a healthy lifestyle, adequate hydration, and regular meal and sleep times can help you reduce susceptibility to migraine triggers.
* Name changed
A. David Rothner, MD, isDirector of the Pediatric/Adolescent Headache Clinic and Chairman Emeritus of Child Neurology at the Cleveland Clinic Foundation in Cleveland.
