Menstrual Migraines: Symptoms, Types, Causes and Treatment

Menstrual migraines are a significant and often debilitating challenge for many women around the world. Unlike typical migraines, these headaches are closely linked to the hormonal shifts that occur during the menstrual cycle. Understanding how menstrual migraines manifest, what causes them, and how they can be managed is crucial for improving quality of life. This article offers a comprehensive guide to the symptoms, types, underlying causes, and current treatment options for menstrual migraines, synthesizing the latest scientific evidence.

Symptoms of Menstrual Migraines

Menstrual migraines are notorious for their intensity and the way they can disrupt daily life. While they share many similarities with other types of migraines, research indicates that certain symptoms are more pronounced and the overall impact can be greater. Recognizing these symptoms is the first step toward effective management.

Symptom	Description	Comparison to Non-Menstrual Migraine	Sources
Duration	Headaches last longer (often >24h)	Longer duration	1 3 4
Intensity	More severe pain	Greater intensity	3 4 5
Nausea	Frequent and pronounced	More common	1 4
Photophobia	Increased sensitivity to light	More pronounced	1 3 4
Phonophobia	Increased sensitivity to sound	More pronounced	1 3 4
Allodynia	Pain from normally non-painful touch	More frequent	1
Aura	Less likely to occur	Less common	3 5

Table 1: Key Symptoms

What Makes Menstrual Migraine Symptoms Unique?

Menstrual migraines often stand out because their symptoms are not only more frequent around menstruation, but also more challenging to manage.

Longer and More Intense Attacks

• Studies consistently show that menstrual migraines last longer than non-menstrual migraines—often extending beyond 24 hours—and are more severe in intensity. Women report that the pain is harder to control and more disabling, sometimes leading to a higher risk of recurrence if a headache returns after the initial attack subsides 1 3 4.
• These attacks are also more likely to be resistant to standard acute treatments, increasing the risk of medication overuse 3.

Accompanying Symptoms

• Nausea, photophobia (light sensitivity), and phonophobia (sound sensitivity) are more commonly reported among women experiencing menstrual migraines than those with migraines unrelated to menstruation 1 4.
• Allodynia, or pain from stimuli that are not usually painful (such as brushing hair), is also more frequently observed in menstrual migraine sufferers 1.

Aura and Premonitory Symptoms

• Menstrual migraines are less likely than other migraine types to be accompanied by aura (visual or sensory disturbances that precede the headache) 3 5.
• However, premonitory symptoms—early warning signs like fatigue, mood changes, or cravings—may be more common in women with menstrually related migraines 1.

Impact on Daily Life

• The increased severity and duration of menstrual migraines often result in greater disability and a higher impact on work, household, and non-work activities compared to non-menstrual migraine attacks 3 4.
• While the pain intensity is only slightly greater during menses, the longer duration of the attacks significantly contributes to a worse overall experience 5.

Types of Menstrual Migraines

Not all migraines that occur during menstruation are classified the same way. Recognizing the different types helps guide diagnosis and treatment decisions.

Type	Definition	Prevalence Among Migraineurs	Sources
Pure MM	Only occur between days -2 to +3 of menstruation, in ≥2/3 cycles	~7-8%	7
Menstrually Related MM (MRM)	Occur during menstruation and at other times	~13-17%	6 7
With Aura	Migraine with neurological symptoms (aura) linked to menstruation	Less common (<2%)	6

Table 2: Types of Menstrual Migraine

Understanding the Classification

Pure Menstrual Migraine (PMM)

• PMM refers to migraine attacks that occur exclusively around menstruation—specifically from two days before to three days after the onset of bleeding—in at least two out of three cycles. These attacks do not occur at any other time of the cycle 7.
• PMM is less common than other types, accounting for less than 10% of female migraineurs 7.

Menstrually Related Migraine (MRM)

• MRM is diagnosed when migraine attacks occur during the perimenstrual window but also at other times in the cycle. This is the most common type, affecting about 13-17% of female migraineurs 6 7.
• The majority of menstrual migraines are without aura, but a small proportion can have aura symptoms 6.

Migraine With Aura

• Menstrual migraine with aura—characterized by visual or sensory changes before the headache—is relatively rare, affecting less than 2% of women with menstrual migraines 6.

Diagnostic Challenges

• Diagnostic criteria for menstrual migraines are still evolving and are primarily included in the appendix of the International Classification of Headache Disorders, reflecting the need for ongoing research and better standardization 7 12.
• Many women may not fit neatly into one category, and self-reporting can vary widely, making prevalence figures somewhat variable across studies 6 7 12.

Epidemiological Insights

• Population studies show that among women aged 30-44, around 21-22% report menstrual migraine (PMM or MRM combined), making it a common problem in this age group 6 7.
• Prevalence estimates can be higher in clinical settings, suggesting that women with more severe or disabling symptoms are more likely to seek medical help 11.

Causes of Menstrual Migraines

The link between hormonal fluctuations and migraines is complex, but understanding the underlying causes can help tailor prevention and management strategies.

Cause	Mechanism or Factor	Notable Details	Sources
Estrogen Withdrawal	Drop in estrogen triggers migraine susceptibility	Main hypothesis	8 10 11 12
Prostaglandin Release	Increased prostaglandins during menstruation	May exacerbate pain sensitivity	11 12
Trigeminovascular Sensitivity	Hormones modulate pain pathways in the brain	Affects severity and frequency	10 12
Risk Factors	Dysmenorrhea, contraceptive use, lifestyle	Irritability, cola, etc.	9

Table 3: Underlying Causes and Risk Factors

Hormonal Fluctuations: The Central Trigger

Estrogen Withdrawal

• The leading theory is that the rapid drop in circulating estrogen that occurs in the days just before menstruation triggers migraine attacks in susceptible women 8 10 11 12.
• Estrogen is thought to modulate pain sensitivity, particularly through its effects on the trigeminovascular system—a key pathway in migraine pathophysiology 10.
• The "estrogen withdrawal hypothesis" is widely accepted, but direct evidence is still limited, and more research is needed to fully understand its role 10.

Prostaglandin Release

• During menstruation, the release of prostaglandins (compounds involved in inflammation and pain) increases. This may further lower the threshold for migraine attacks or exacerbate their severity 11 12.
• Prostaglandins may also explain why menstrual migraines are often more resistant to typical painkillers.

Neurovascular and Neuroinflammatory Mechanisms

• Hormonal fluctuations influence the expression of neuropeptides such as calcitonin gene-related peptide (CGRP), which is implicated in migraine and neurogenic inflammation 12.
• Gonadal hormones can also affect susceptibility to cortical spreading depression, a phenomenon associated with migraine aura 12.

Risk Factors and Susceptibility

• Menstrual migraines are more common in women who also experience dysmenorrhea (painful periods), use hormonal contraceptives, or report symptoms such as menstrual irritability and dizziness 9.
• Lifestyle factors, like frequent consumption of caffeinated beverages (such as cola), may also increase risk 9.
• Despite the overlap in timing, the presence of premenstrual syndrome (PMS) symptoms does not appear to predict who will develop menstrual migraine 2 3.

Complexity and Unanswered Questions

• Not all women with hormonal fluctuations develop migraines, suggesting a genetic or environmental susceptibility 12.
• The exact interplay between hormones, the brain, and migraine triggers remains an active area of research 10 11 12.

Treatment of Menstrual Migraines

Managing menstrual migraines can be challenging due to their increased severity and resistance to standard therapies. Both acute and preventive strategies are available, and treatment should be individualized.

Approach	Example Medications/Methods	Best Use Case	Sources
Acute Treatment	Sumatriptan, Rizatriptan, NSAIDs	At onset of migraine	13 14 16 17
Short-term Prevention	Frovatriptan, Naratriptan, Estrogen patch	Perimenstrual prophylaxis	13 16 17
Hormonal Therapy	Transdermal estradiol	For women with predictable cycles	13 16
Lifestyle Mods	Reducing triggers, tracking cycles	Adjunct to medication	9 14

Table 4: Treatment Strategies for Menstrual Migraine

Acute Treatment Options

• Triptans: Sumatriptan (50-100 mg), rizatriptan (10 mg), and combination sumatriptan/naproxen have strong evidence for effectiveness in aborting menstrual migraine attacks. Sumatriptan 100 mg is the most effective for acute relief 13 16 17.
• NSAIDs: Mefenamic acid (500 mg) is another option, especially for women who may not tolerate triptans 13 16.
• Despite these options, acute treatment is often less effective for menstrual migraines than for non-menstrual migraines, with higher rates of headache recurrence 3 13 16.

Short-term (Perimenstrual) Prevention

• Frovatriptan (2.5 mg twice daily) and naratriptan (1 mg twice daily), started 1-2 days before expected onset of menses and continued for several days, are the most effective for short-term prevention, reducing both attack frequency and severity 13 16 17.
• Transdermal estradiol (1.5 mg) applied before and during menstruation can reduce the risk of attacks for women with predictable cycles 13 16.

Hormonal Strategies

• In women who require contraception, continuous or extended-cycle hormonal contraceptives may be considered to reduce the frequency of hormone fluctuations and thus migraine attacks 16.
• However, hormonal strategies must be tailored to individual risk profiles and discussed with a healthcare provider.

Lifestyle and Non-Pharmacological Approaches

• Tracking migraine patterns and avoiding known triggers (such as caffeine, stress, or lack of sleep) can play a supportive role 9 14.
• Addressing coexisting menstrual symptoms (like dysmenorrhea) can also help manage overall disability 9.

Treatment Challenges and Future Directions

• Menstrual migraines tend to be more disabling, longer-lasting, and more difficult to treat than migraines at other times, so a multi-pronged approach is often needed 13 16 17.
• Despite available options, many women remain undertreated or dissatisfied with current therapies, highlighting the need for further research and more personalized treatment strategies 11 12 14 15.

Conclusion

Menstrual migraines represent a unique and challenging subset of migraine disorders, closely linked to the hormonal fluctuations of the menstrual cycle. Through a careful synthesis of research, several key patterns emerge:

• Symptoms: Menstrual migraines are characterized by longer duration, greater intensity, and more pronounced associated symptoms (nausea, photophobia, phonophobia, allodynia) than non-menstrual migraines.
• Types: The two main types are pure menstrual migraine (PMM) and menstrually related migraine (MRM), with MRM being more common and both usually occurring without aura.
• Causes: Hormonal changes, especially estrogen withdrawal and increased prostaglandin release, are central triggers, with susceptibility influenced by genetics, lifestyle, and other risk factors.
• Treatment: Both acute and preventive treatments are available, with triptans and NSAIDs effective for acute attacks, and perimenstrual prophylaxis (e.g., frovatriptan, naratriptan, transdermal estrogen) recommended for prevention. Lifestyle management and hormonal strategies may also be beneficial.

Key Takeaways:

• Menstrual migraines are more intense and disabling than non-menstrual migraines.
• Accurate diagnosis and understanding of migraine type are crucial for effective management.
• The main trigger is hormonal fluctuation, particularly a drop in estrogen.
• Short-term preventive therapy is effective for many women, especially those with predictable cycles.
• Ongoing research is needed to refine treatment and address unmet needs for women with menstrual migraines.

By recognizing the distinct characteristics of menstrual migraines and applying evidence-based treatment, women and their healthcare providers can work toward minimizing the disruption and enhancing quality of life.