Menstrual migraine

**Menstrual migraine** (also called *catamenial migraine*) is 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 migraneurs experience migraine attacks throughout the menstruation cycle with an increased number at the time of menstruation. These are called *menstrually related* or *menstrually triggered migraine*.

It used to believed that treatments for migraine would work in menstrual migraine but that has not proven to be the case. 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 sometime 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% 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 in 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 affect certain parts of the brain, usually the parts that control vision but they can also affect the parts of the brain which control the other senses like touch, motor control (moving parts of the body) and the parts of the brain that control speech.
## Symptoms
### Warning symptoms
 estrogen. Stopping use of the pill causes a woman's estrogen levels to drop; that may cause a menstrual migraine in some women.]]

Warning symptoms also called *prodrome symptoms* often happen before a migraine attack.
* 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 symptoms
A pounding throbbing headache with the pain being on one side of the head (unilateral). The side of the head that has the pain changes from one headache to the next.

## Diagnosis

**International Headache Society classification of pure menstrual migraine and menstrually related migraine**

**A1.1.1 Pure menstrual migraine without aura** 
Symptoms of this kind of migraine: 
A. Attacks, in a menstruating woman, that have symptoms the same as ‘1.1 Migraine without aura'
B. Attacks occur only on Day 1 ± 2 (that means: Days +2 to –3) of menstruation in at least two out of three menstrual cycles and at no other times of the cycle.
C.A menstruation cycle is the amount of time between a woman's periods. The cycle starts from the start of one period and ends at the start of the next one. One cycle is usually is 28 days long.
Notes:
1. The first day of menstruation is Day 1 and the day before is Day –1; there is no Day 0.
2. To have Pure menstrual migraine, menstruation here means when normal bleeding happens in a normal menstruation cycle or when the woman stops taking hormones, like birth control pills.
**A1.1.2 Menstrually-related migraine without aura**
Symptoms of this kind of migraine: 
A. Attacks, in a menstruating woman, that have symptoms the same as ‘1.1 Migraine without aura’
B. Attacks occur on Day 1 ± 2 (that means: Days –2 to +3) of menstruation in at least two out of three menstrual cycles plus at other times of the cycle
Notes: 
1. The first day of menstruation is Day 1 and the day before is Day –1; there is no Day 0.
2. To have Menstrually-related migraine without aura, menstruation here means when normal bleeding happens in a normal menstruation cycle or when the woman stops taking hormones, like birth control pills
adapted from the International Headache Society

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 occur usually 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 with aura reported in 2012.

The *Menstrual Migraine Assesment Tool* is a simple questionnaire with three questions, that has shown to be fairly accurate in diagnosing menstrual migraine. 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 cause light to bothers 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.
## Comorbidities
Often, having one medical condition makes it more likely 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)**: is when asthma symptoms get worse during the premenstrual period. This condition may affect up to 40% of female asthma sufferers. 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 this to be lowered in the premenstrual period). It is helpful in making a diagnosis to keep a diary of symptoms and peak expiratory flow rates.

:Raynaud’s disease: 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

**Comorbid psychiatric conditions**
:Major depressive disorder 
:Anxiety 
:Bipolar disorder

## Prevention
There are treatments which are used for menstrual migraines which may reduce how many times a woman gets them and how bad they are. This kind of treatment is called *prophylactic therapy* and it is used in the perimenstrual period which is the time between periods.

Prophylactic therapy for menstrual migraine should be tried for at least 3 menstruation cycles to see if that works before it is stopped. Medications used may include:
*NSAIDS (nonsteroidal antinflammatory drugs):
1. Napraxen sodium such as Aleve
*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.
## Treatment
*Acute treatments* (short-term treatment) include Nonsteroidal anti-inflammatory drugs that help stop *inflammation* which is redness, swelling, pain, tenderness, 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 worn on the skin.

## 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.

## References
## Other websites
*Optimizing Management of Menstrual Migraine http://www.jfponline.com/uploadedFiles/Journal_Site_Files/Journal_of_Family_Practice/supplement_archive/1205JFP_Supplement.pdf