Robert Cowan

Thanks to Adrie from South Africa for this question about migraine attacks around the time of her menstrual period (ask your own question here!).

First, a quick definition, because it is important for treatment. There are two classes of migraine here. One is menstrually-related migraine. This is when attacks occur at least 2/3 of the time day -2 to +3 of your menstruation, but attacks also occur other times of the month.

For the purpose of this question, however, we’ll focus on pure menstrual migraine, in which attacks occur 2/3 of the time day -2 to +3 of your cycle, but at no other time. (Here’s a summary of menstrual migraine in graphic form.)

There is no doubt that hormones are related to these attacks – but, surprisingly, just how they’re related is a bit of a mystery. The theory that we should simply be able to adjust hormone levels to solve the problem has not been the silver bullet.

Adrie is actually already a ways down the road searching for treatment, but hopefully we can help her or some other reader consider some options that haven’t been investigated fully. And remember, we’re speaking more generally anyway, because we will not diagnose a specific case here (even if we had enough information, which we don’t).

But first, the “treatment” that should not be tried – hysterectomy. Dr. Robert Cowan explains well in his book The Keeler Migraine Method:

In the past, doctors tried to modify this trigger through hysterectomy but today we know that hysterectomy will not improve migraines and can in fact make them significantly worse. Hysterectomy causes chaos in estrogen levels, estrogen receptors, and the chemicals that estrogen modifies. A migraineur’s brain does not like chaos. It likes things nice and regular and predictable.

So what are better options? Here are a few:

• All-month Lifestyle: If certain things make your attacks worse, don’t fall into the trap of being careful only when the symptoms start. Even something you do days before can impact your symptoms. Are you eating properly? Getting enough sleep? A healthy diet and balanced lifestyle overall can improve things significantly.
• Drug options: Taking an abortive even before the attack hits, or early on, can help you avoid the migraine monster. NSAIDs are commonly prescribed. One of the most helpful targeted migraine drugs is frovatriptan, taken twice a day for five days starting two days before you expect your menstrual cycle to begin. Here’s a quick summary of other medications.
• Hormone Replacement Therapy: If I understood correctly, this is something Adrie is trying, but so far without success. This has helped many women, but again, it’s not the solution for everyone.
• Contraceptive Changes: If you’re using a contraceptive that’s affecting your hormones, there are a number of options you could try, either to help narrow down what’s causing the problem, or to alleviate symptoms. For example, trying a low-estrogen pill, or investigating other forms of contraception.
• Hydration: Dr. Angela Stanton, the “Queen of Hydration” thanks to her book Fighting the Migraine Epidemic, discusses in detail systems of hydration for migraineurs. Jumping of current research into the reason for menstrual migraine, she suggests that the female brain needs more “voltage” to run the menstrual cycle. Her suggestion (along with her full system that you can read about in the book) is to prepare 5 days ahead – no sugar, and more water (along with more salt). In her system, that would be an extra glass of water and an extra salt pill a day.
• Preventative Medications: Preventative meds should be used cautiously with pure menstrual migraine, because they will affect your body 24-7, not just once a month. However, in severe cases, doctors may suggest a preventative.
• Supplements: Adrie has tried some supplements without success. But some of the top ones include magnesium (and if one doesn’t work, try another – see Which Magnesium Supplements Work?) and vitamin E.
• Other Treatments: If drugs can be avoided, or fewer drugs taken, that’s a better road to travel. Some excellent treatments include biofeedback, massage, deep breathing, and essential oils.

Final note: Keep a diary. Keeping track of your attacks is extremely important with menstrual migraine, even though you would think it isn’t. Some women find that, for example, when they give into a premenstrual craving, they make symptoms worse. Dr. Cowan, mentioned above, gives one story of a patient that illustrates well the need to keep track:

Partial triggers may show up in association with other triggers. For example, I had a patient who got her most severe headaches when she had her nails done during her period but not at other times. It took her about four months of journaling to pick this up. When she changed salons to a place that didn’t use heavy lacquers, she was fine.

Menstrual migraine is a difficult beast to fight (see 8 Reasons why Menstrual Migraine is “different”). But there are good solutions out there. Feel free to leave a comment, letting us know what has worked well for you!