# Menstrual migraine

Menstrual migraine (also called catamenial migraine) is the term used to describe both true menstrual migraines and menstrually related migraines. About 7%–14% of women have migraines only at the time of menstruation. These are called true menstrual migraines. Most female migraineurs experience migraine attacks throughout the menstruation cycle with an increased number perimenstrually, these are referred to as menstrually related or menstrually triggered migraine.
It used to be believed that treatments for migraine would work in menstrual migraine, but that has not proven to be the case. Menstrual migraines are harder to treat. Because of this, menstrual migraines are now considered a separate medical disorder from migraine. In 2008, menstrual migraines were given ICD-9 codes (346.4-346.43) of their own which separate menstrual migraine from other types of migraine.
About 40% of women and 20% of men will get a migraine at some time in their life. Most of them will get their first migraine before they are 35 years old. Menstrual-related migraines happen in more than 50 percent of women who have migraine headaches. Menstrual migraine attacks usually last longer than other migraine attacks, and short-term treatments do not work as well with menstrual migraine as they do with other kinds of migraine. They are usually migraines without aura, but in 2012 a case of menstrual migraine with aura was reported, so it is possible. Auras are a kind of condition which affects certain parts of the brain, usually the parts that control vision but they can also affect the parts of the brain which control other senses like touch, motor control (moving parts of the body) and the parts of the brain that control speech.

## Signs and symptoms
### Warning symptoms

Warning symptoms, also called prodrome symptoms, often happen before a migraine attack. These include:
* Sleepiness
* Fatigue
* Depression (feeling sad), euphoria (feeling very happy) or irritability
* Restlessness
* Excessive (too much) yawning
* Food cravings especially for sweet or salty foods or loss of appetite
* Increased thirst
* Diarrhea
* Nausea
* Bloating: the body retains (keeps) too much water
* Neck stiffness
* Talkativeness (talking too much)
* Feeling light-headed
* Uterine pain and cramping

### Headache

A pounding throbbing headache with pain on one side of the head (unilateral). The headache often moves from one side of the head to another.

### Associated conditions

Often, having one medical condition makes it more likely that a person will also have one or more other medical or psychiatric disorders. These other disorders are the "comorbid disorders" or "comorbidities". There are various comorbid medical and psychiatric conditions associated with migraines. The treatment and prognosis (if a disease gets better, worse or stays the same over time) of migraine is affected by the comorbid disorders which may be present and/or the chance of getting comorbid disorders.
* Asthma – Premenstrual asthma (PMA): This is when asthma symptoms get worse during the premenstrual period. This condition may affect up to 40% of females with asthma. For a diagnosis of PMA to be made, it is necessary to have a detailed history of the timing of menstrual cycles along with asthma symptoms experienced, and the peak expiratory flow rate (PMA may cause the PEF to be lowered in the premenstrual period). In making a diagnosis, It is helpful to keep a diary of symptoms and peak expiratory flow (PEF) rates.
* Raynaud's disease: This is a circulatory disorder in which the smaller arteries that supply blood to the extremities – most often the hands, but it may also affect the toes, the tip of the nose and the ears – become narrower reducing blood flow. This causes the extremities to become numb and to be cooler than the core body temperature. It can be triggered by exposure to stress and cold.
* Epilepsy
* Fibromyalgia
It is associated with a number of mental health conditions, including:
* Major depressive disorder
* Anxiety
* Bipolar disorder

## Causes

The exact causes of menstrual migraine are not known for sure, but there is a link between falling levels of the female hormone estrogen and the onset of a migraine attack. The estrogen level may fall after bleeding occurs during the menstrual cycle or when external sources of estrogen are no longer taken, like when a woman stops taking birth control pills or hormone pills in hormone replacement therapy.

## Diagnosis

The diagnosis of a menstrual migraine is made by keeping track of when the migraines occur for a period of at least three months. Menstrually related migraine attacks usually occur between 2 days before and 3 days after the start of menstruation in at least 2 out of 3 menstrual cycles (periods) in a row. Pure menstrual migraine and menstrually related migraine are both migraines without auras, with one exceptionally rare case of migraines with aura reported in 2012.
The Menstrual Migraine Assessment Tool (MMAT) is a simple questionnaire with three questions that has shown to be fairly accurate in diagnosing menstrual migraine (Tepper SJ, 2008). The three questions are:
* Do migraines occur in the space of time 2 days before the beginning of a woman's period until the third day after the start of the period? And does this happen in most months?
* Do headaches that happen during this time become very severe?
* Does the woman experience photophobia (which is when a medical problem causes light to bother a person's eyes)?
The answer to the first question has to be yes, and there has to be at least one yes answer to either question 2 or question 3.
In order to keep track of what time of the month the migraines happen, it is helpful to use a headache diary. A person uses the headache diary to write down information about their headaches, like when they started, what kind of symptoms they had and how bad the pain was etc.

## Prevention

There are treatments which may decrease the severity or frequency of menstrual migraines. Preventative treatments for menstrual migraine should be tried for at least 3 menstruation cycles to determine effectiveness.
Medications used may include:
* NSAIDS (nonsteroidal antiinflammatory drugs) such as naproxen
* Beta blockers—such as propranolol, nadolol, atenolol, and metoprolol
* Tricyclic antidepressants (TCAs) and other kinds of antidepressant medications are often used for migraine prevention. These include amitriptyline, nortriptyline, and doxepin.
* Prophylactic use of estrogen containing contraceptives

## Treatment

Acute treatments (short-term treatment) include drugs called Nonsteroidal anti-inflammatory drugs (NSAIDs) (drugs that help stop inflammation which is redness, swelling, pain, tenderness, and heat in parts of the body); triptans such as Frovatriptan, ergotomines which are a kind of drug made from a fungus called ergot; and estrogen transdermal patches, which are patches worn on the skin that have estrogen in them which enters the body through the skin and then into the bloodstream.