Let’s “See”, How Common are Migraines and The Education and Management of the Menstrual Migraine

• 1 billion suffer worldwide
• 1 in 4 Households
• 1 in 5 Women
• 1 in 16 Men
• 1 in 11 children

Primary headaches, such as migraine and Tension-Type Headache (TTH), are also disorders mediated by the trigeminal system that can be chronic and disabling, affecting over 15% of the US population at any one time and costing the US economy over $19.6 billion a year. Migraine is a primary disorder of the brain explained as a neurovascular disorder in which neural events result in meningeal blood vessel dilation, which results in further nociceptive activation of the trigeminovascular system. Neurovascular disorders, such as primary headaches, can present as chronic orofacial pain, such as in the case of facial migraine, where the pain is localized in the second and third division of the trigeminal nerve. Together, these disorders of the trigeminal system impact the quality of life of the sufferer dramatically. This video below from Association of Migraine Disorders is well worth the 10 minutes to watch so I can help tie the reason so many folks with migraines can suffer facial pain or temporomandibular pain, and vice versa! After all, my specialty, and most of my readers, are in the area of treating Temporomandibular Disorders, Orofacial Pain, and Craniofacial Pain. 

What Causes Migraine Disease? 5 Factors in Migraine Neurobiology Great Video!

Menstrual Migraine

Today I wanted to focus on the impact of menstruation on migraine for women, including information and treatment options on menstrual migraine.

While many women report that menstruation is a migraine trigger, there is a specific condition known as ‘menstrual migraine.’

Menstrual migraine is associated with falling levels of estrogen. Studies show that migraine is most likely to occur in the two days leading up to a period and the first three days of a period. This type of migraine is thought to affect fewer than 10% of women. 

The two most accepted theories on the cause for menstrual migraine, at the moment, are:

• The withdrawal of estrogen as part of the normal menstrual cycle and 
• The normal release of prostaglandin during the first 48 hours of menstruation.

There are no tests available to confirm the diagnosis, so the only accurate way to tell if you have menstrual migraine is to keep a diary for at least three months recording both your migraine attacks and the days you menstruate. This will also help you to identify non-hormonal triggers that you can try to avoid during the most vulnerable times of your menstrual cycle.

Treating Menstrual Migraine

There are several treatment options depending on the regularity of your menstrual cycle, whether or not you have painful or heavy periods, menopausal symptoms, or you also need contraception. Although none of these options are explicitly licensed for menstrual migraines, they can be prescribed for this condition if your doctor feels they would benefit you.

If you have a migraine and heavy periods, taking an anti-inflammatory painkiller such as mefenamic acid or Ponstel, is the brand name, could help. Mefenamic acid is an effective migraine preventive and is also considered to help reduce migraines associated with heavy and/or painful periods. A dose of 500 mg can be taken three to four times daily. It can be started 2 to 3 days before the expected start of your period. If your periods are not regular, it is often useful when started on the first day. It is usually only needed for the first two to three days of your period. Naproxen can also be effective in doses of around 500 mg once or twice daily around menstruation.

You may wish to discuss using estrogen supplements with your doctor. Topping up your naturally falling estrogen levels just before and during your period might help if your migraine occurs regularly before your period. Estrogen can be taken in several forms, such as skin patches or gel. You put the patch on your skin for seven days, starting from 3 days before your period’s expected first day. Similarly, you rub the gel onto your skin for seven days. In this way, the estrogen from the patch or gel is absorbed directly into your bloodstream. You should not use estrogen supplements if you think you are pregnant or are trying to get pregnant. Keeping a diary of your migraines will help you to judge when best to start the treatment.

If your periods are irregular, your doctor may suggest other ways to maintain your estrogen levels at a more stable rate, such as a combined oral contraceptive pill. The acute treatment of menstrual-related attacks is no different from non-menstrual attacks. Head-to-head studies do not show a clear superiority of one triptan over any other. Recommended short term preventive treatments for menstrual-related migraine, or pure menstrual migraine are noted below:

Recommended triptans for short term prevention of menstrually related migraine or pure menstrual migraine:

All treatments for short term prevention of menstrually related migraine or pure menstrual migraine:

Taken from the British Association for the Study of Headache’s National Headache Management System for Adults 2019

In recognition of Migraine Awareness Month, I hope this provided some insight into some of your patients suffering from Migraines, Facial Migraines, and Menstrual Migraines.

As always, in the search to provide excellent care for our patients suffering from Craniofacial pain-related Disorders!

Yours Truly,

Michael Karegeannes