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Management of Migraine Associated with Menses Companion Guide

The presentation companion guide is designed to provide the learner with additional information regarding menstrual migraine as well as relevant resource links.

Menstrual migraines are associated with significant disability, tending to be more severe and longer lasting than non-menstrual migraines. The treatment of menstrual migraine can be categorized into acute/abortive and prophylactic therapies. Acute therapies are similar to those utilized for non-menstrually related migraines. Because of the regular nature of the menstrual cycle, however, menstrual migraine may be predicted and prevented with certain prophylactics.

Abortive therapies include 5HT-1 agonists and analgesics. Randomized controlled trials of sumatriptan indicate that 50 mg and 100 mg oral doses are effective in decreasing the pain of menstrual migraine.¹ Subcutaneous administration of sumatriptan 6 mg also provides significant relief of menstrual migraine when compared with placebo. Prospective studies reveal that sumatriptan is an effective acute therapy for menstrual migraine, both within and outside of the menstrual time frame.² The adverse events reported by those taking sumatriptan are nonserious, and include dizziness, nausea, pressure/tightness, and feelings of warmth.^1,2

Zolmitriptan, another 5HT-1 agonist, is also effective at relieving the pain of menstrual migraine but is associated with a higher frequency of nonserious adverse events.^1,3 Forty-eight percent of participants reported a decrease in pain within two hours, and 45% remained pain free at four hours.³ It is especially important to balance the benefits of this agent with the high possibility of adverse events before prescribing it for menstrual migraine.

Frovatriptan is the newest member in the class of triptans. It is unique among the triptans in that it has a much longer half-life, thus making it a useful drug for patients whose migraines are long lasting. It also has a slower onset of action than other triptans.⁴ Taking frovatriptan at the first sign of a migraine has been shown to prevent mild migraines from progressing to a more severe migraine within 1 to 4 hours postdose.⁵ The adverse effects associated with frovatriptan are similar to that of the other triptans, and include nausea, dizziness, tingling, dry mouth, and chest pains.⁴

Rizatriptan 10 mg has been shown to provide a significant number of patients with pain relief sustaining 24 hours postdose. Additionally, two-thirds of patients reported being pain free two hours postdose. Rizatriptan is an effective abortive therapy when taken within two hours of migraine onset and when the pain is mild.⁶

Although triptans are classically used for acute management, naratriptan has been studied for use as a mini-prophylaxis. Naratriptan 1 mg twice daily reduced the number of menstrual migraine episodes compared to placebo and to higher doses of naratriptan.⁷ Prescribed for use perimenstrually, naratriptan 1 mg may have moderate benefit in the prevention of menstrual migraine, although it should not be used by women with cardiac problems.¹

Mini-prophylaxis with zolmitriptan 2.5 mg thrice daily is another option in the prevention of menstrual migraine.⁸ Because it should be taken at least twice daily for benefits to be seen, and for six days perimenstrually, this option may be cost prohibitive for some women. The same is true for frovatriptan 2.5 mg twice daily perimenstrually.⁹

Nonsteroidal anti-inflammatory drugs (NSAIDs) may provide some relief to certain women suffering from menstrual migraine. A randomized controlled trial showed that 550 mg naproxen sodium twice daily decreased the length and severity of migraines over time, as compared to placebo.¹⁰ The ratio of risks to benefits for the use of naproxen in menstrual migraine is unclear, however.¹ Some patients find naproxen useful as an adjunct therapy to triptans, as it is a less costly drug.⁸

Because of the intimate relationship between estrogen levels and the onset of menstrual migraine, hormone therapies have been suggested. Both oral and transdermal routes of estrogen delivery have shown to be effective in reducing the severity of menstrual migraine, although non-oral routes are preferred to reduce the risk of ischemic stroke.¹¹ Extended, placebo-free regimens of oral contraceptives have also shown to be effective at reducing headache severity.¹² Significant evidence exists supporting the use of estradiol gel 1.5 mg perimenstrually for the reduction of menstrually related migraine, and the benefits typically outweigh any risks.¹

For women suffering from menstrual migraine, several treatment options exist. If the woman has a regular menstrual cycle, she may find it beneficial to undergo mini-prophylaxis with naratriptan, zolmitriptan, frovatriptan, or an estrogen gel during the perimenstrual window. Should symptoms of menstrual migraine arise, the research indicates symptom reduction with the use of sumatriptan, zolmitriptan, or frovatriptan. Occasionally NSAIDs may be beneficial as well.

Resource Links

National Headache Foundation
www.headaches.org/education/Headache_Topic_Sheets/Menstrual_Migraine
American Headache Society
www.americanheadachesociety.org/assets/MartinMigriane.pdf

References

1. Pringsheim T, Jeptha W, Dodick D. Acute treatment and prevention of menstrually related migraine headache. Neurology. 2008;70:1555-1563.
2. Facchinetti F, Bonellie G, Kangasniemi P, Pascual J, Shuaib A. The Sumatriptan Menstrual Migraine Study Group. The efficacy and safety of subcutaneous sumatriptan in the acute treatment of menstrual migraine. Obstet Gynecol. 1995;86(6):911-916.
3. Loder E, Silberstein SD, Abu-Shakra S, Mueller L, Smith T. Headache. 2004;44:120-130.
4. National Headache Foundation. Frovatriptan. Accessed August 5, 2009 at: www.headaches.org/education/Medications/Frovatriptan_-_Frova
5. Cady R, Elkind A, Goldstein J, Keywood C. Randomized, placebo-controlled comparison of early use of frovatriptan in a migraine attack versus dosing after the headache has become moderate or severe. Curr Med Res Opin. 2004;20(9):1465-1472.
6. Cady RK, Martin VT, Geraud G, Rodgers A, Zhang Y, et al. Rizatriptan 10 mg ODT for early treatment of migraine and impact of migraine education on treatment response. Headache. 2009;49(5):687-696.
7. Newman L, Mannix LK, Landy S, Silberstein S, Lipton RB, et al. Naratriptan as short-term prophylaxis of menstrual migraine: A randomized, double-blind, placebo-controlled study. Headache. 2001;41(3):248-256.
8. Tuchman M, Hee A, Emeribe U. Oral zolmitriptan 2.5 mg demonstrates high efficacy and good tolerability in the prophylactic treatment of menstrual migraine headaches. Headache. 2005;45(6):771-772.
9. Hutchinson S. Prevention and management of menstrual migraine. Curr Headache Reports. 2007;6:164-168.
10. Sances G, Martignoni E, Fioroni L, Blandini F, Facchinetti F, Nappi G. Naproxen sodium in menstrual migraine prophylaxis: A double-blind placebo controlled study. Headache. 2001;30(11):705-709.
11. MacGregor EA, Frith A, Ellis J, Aspinall L, Hackshaw A. Prevention of menstrual attacks of migraine: A double-blind placebo-controlled crossover study. Neurology. 2006;67(12):2159-2163.
12. Sulak P, Willis S, Kuehl T. Coffee A, Clark J. Headaches and oral contraceptives: Impact of eliminating the standard 7-day placebo interval. Headache. 2007;47(8):27-37.