Extreme lethargy and mood swings Reviewed by Jasmin Harpe, MD, MPH Author and Disclosure Information [Show] Jasmin Harpe, MD, MPH, Headache Fellow, Department of Neurology, Harvard University, John R. Graham Headache Center, Mass General Brigham, Boston, MA.Jasmin Harpe, MD, MPH, has disclosed no relevant financial relationships. Question 1 of 3 A 39-year-old married woman with three elementary school–aged children presents to her primary care physician reporting debilitating migraines during her period for the last four of six cycles. Her headaches begin approximately 2 days before the start of menses and continue for the first 3 days of her cycle. She has recorded her symptoms and reports extreme lethargy and mood swings, which include irritability and depression, as well as food cravings for both salty and sweet foods in the days before onset of her headaches. She does not experience aura with her migraines but does experience extreme nausea and both photo- and phonophobia, which require her to be bedridden in a dark room for several days. She has taken nonsteroidal anti-inflammatory drugs (NSAIDs) to relieve her pain, but they take several doses to provide relief, if at all. She reports feeling exhausted and "washed out" at the end of these episodes but is also much relieved and feels lighter overall. The patient's medical history is otherwise unremarkable. She doesn't experience headaches at any other time during the month but does have a positive family history of headache (mother). Other than triphasic oral contraceptives, which she began taking a year ago, she does not take any medication.What is the likely cause of this patient's migraine headaches? Choose one Decline in serum estradiol levels Increase in serum estradiol levels Increase in serum progesterone levels Decrease in serum progesterone levels This quiz is not accredited for CME.