Menstrual Migraine Poses Challenges for Both Doctors and Patients

BY MAURY M. BREECHER
Contributing Writer

ORLANDO - (ECCC) Menstrual migraine (MM) poses unique challenges to doctors because they are more severe, last longer, and are less responsive to acute treatment than non-menstrual migraine attacks, said Dr. Lisa K. Mannix on July 19 during a headache symposium sponsored by the Diamond Headache Clinic Research and Educational Foundation.

“Conceptually, we have understood for a long time that migraines often occur during the menses, but until 2004 we didn't have a standard definition, so some neurologists denied the existence of menstrual migraines,” said Dr. Mannix, medical director of Headache Associates in Cincinnati.

Dr. Mannix reported that menstrual migraine is more likely to cause work-related disability and more likely to recur. In 2004, the International Headache Society defined the condition as a migraine without aura that occurs on the first day of bleeding or the 2 days before and the 2 days after that first day in at least 2 out 3 menstrual periods.

The Society's definition specified two forms of MM: pure menstrual migraine (PMM), which only occurs during that 5-day menstrual window, and menstrually-related migraine (MRM), which occurs both perimenstrually and at other times of the month.

Ten percent of women with migraine have PMM. MRM occurs more frequently, with some 50-70% of women with migraines reporting this type of menstrual relationship to headache, said Dr. Mannix.

“Knowing what type of headache the patient has is important because then the patient can be encouraged to maintain a headache calendar,” she explained. “Keeping a calendar or headache diary helps her anticipate when that headache may reoccur, which allows us to develop treatment strategies based on that knowledge.”

Migraine is one of the two most common symptoms associated with menstruation. The other is dysmenorrhea, said Mannix.

“Menorrhagia is more frequent in migraineurs than in women without migraine and migraineurs are significantly more likely to have endometriosis than are women without migraines,” Dr. Mannix said (Contraception 2000;62:277-84, Headache 2006;46:422-8, and Hum. Reprod. 2004;19:2927-32).

Patients with migraines are also likely to suffer from premenstrual mood disorders, such as premenstrual mood syndrome (PMS), said Dr. Mannix. Past research has shown that 64% of those with pure menstrual migraine and 33% with MRM met the criteria for PMS (Cephalalgia 1992;12:356-9, Headache 2006;46:125-37, and Cephalalgia 1993;13:422-45). However, according to the studies migraine, did not increase the frequency or severity of PMS.

Fluctuating hormone levels during the menstrual cycle is thought to be a cause of both migraine and PMS, Dr. Mannix noted.

Dr. Mannix said she has conducted research and/or served as a consultant or speaker in the past for Alexza, Allegan, Endo, GlaxoSmithKline, Merck, Ortho-McNeil Neurologics, Pfizer, and Pozen.

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