Clinical Review

The gynecologist’s role in managing menstrual migraine

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  • moderate or severe pain
  • throbbing
  • unilateral location
  • intensification of headache upon activity.

Any combination of two suffices for diagnosis—much to the astonishment of many patients who mistakenly believe that migraine must be severe or one-sided.

Associated symptoms include either nausea or both photophobia and phonophobia, the latter often signified by the simple preference to be in a dark, quiet room during an attack.

Untreated, migraine usually lasts between 4 and 72 hours.

A practical, clinical approach to diagnosis is to look for the episodic disabling headache. By disabling, I mean the presence of associated nausea or the need to stop one’s activities and lie down. A stable history of attacks with predictable menstrual association offers further confirmation.

Neck tension may be present

Symptoms of neck tension do not rule out migraine. In fact, neck pain is far more common at the time of treatment than is nausea, and migraineurs frequently describe neck pain that radiates forward during an attack.6

Treatment options begin with NSAIDs

Initial treatment of MM is no different than that of other migraines. Mild and moderate attacks can often be managed with nonsteroidal anti-inflammatory drugs (NSAIDs), which concomitantly treat comorbid dysmenorrhea.

A small randomized trial found that mefenamic acid (500 mg every 8 hours, as needed) was superior to placebo for acute MM, and a small crossover trial compared two formulations of diclofenac—50-mg sachets and tablets—with placebo in the treatment of acute migraine (TABLE). Almost one quarter of the patients taking the sachet form were pain-free at 2 hours, compared with 18.5% of patients taking the tablets and 11.7% of those who received placebo.7,8

Injectable ketorolac is more potent and is proving to be as effective as or more effective than triptans or opioids for severe, persistent migraine.

When migraine is more severe, or when NSAIDs no longer suffice, treatment advances to migraine-specific medications—specifically, ergotamines and triptans.

Brand names of drugs mentioned in this article

DrugBrand name
NSAIDs
Diclofenac sodiumVoltaren (and others)
Ketorolac tromethamineToradol (and others)
Mefenamic acidPonstel (and others)
Naproxen sodiumNaprelan (and others)
Triptans
Eletriptan hydrobromideRelpax
Frovatriptan succinateFrova
Naratriptan hydrochlorideAmerge
Sumatriptan succinateImitrex
Ergotamines
Dihydroergotamine mesylateD.H.E. 45, Migranal
Other
Butalbital, acetaminophen, and caffeineFioricet
Leuprolide acetateLupron, Eligard

Ergots and ergotamines have varied safety profiles in pregnancy

Dihydroergotamine belongs to the oldest family of migraine-specific drugs, although it is not widely used today. One reason may be that most migraineurs are women of reproductive age, and ergots are oxytocic and potential teratogens. Furthermore, they are not recommended in lactation. Ergotamines, however, are quite diverse, and some have more acceptable FDA use-in-pregnancy ratings. Injectable dihydroergotamine appears to be as effective as or less effective than triptans for migraine pain, but more effective than other drugs, such as NSAIDs or analgesics, for acute attacks.9 The nasal spray is more effective than placebo, but less effective than triptans.9

Triptans are relatively safe for women of reproductive age

Most information on use of triptans in pregnancy concerns sumatriptan. Like all triptans, it falls into Category C; however, its published profile is reassuring.10-12 Data from Sweden on 2,027 first-trimester exposures show a 3.6% risk of birth defects (major and minor), compared with an identical 3.6% risk in the general Swedish population.12 Sumatriptan is considerably less lipophilic than most of the drugs in its class and has been rated as compatible with breastfeeding.13

All triptans except eletriptan have been studied in the treatment of acute MM and found to be superior to placebo.14 These serotonin 1B/1D agonists are tailored therapy for acute migraine because, unlike analgesics, they address the underlying pathology of the attack, inhibiting the release of vasoactive peptides, promoting selective meningeal vasoconstriction, and blocking pain pathways in the brainstem. They also resolve the associated symptoms of nausea and photophobia. Triptans should not be used in the presence of untreated hypertension or vascular disease (cardiovascular, cerebrovascular, or peripheral vascular disease).

Watch for “rebound” headache. Like all acute treatment—be it a simple analgesic, NSAID, caffeine-containing compound, butalbital, ergotamine, or opioid—too-frequent use of triptans can produce medication-overuse headache, also referred to as rebound headache. In general, try to limit the use of agents for acute migraine, whether prescription or over-the-counter, to no more than 2 days a week to avoid this consequence. Also, be aware that some agents—notably, butalbital-containing compounds—may cause rebound headache, even when given as infrequently as 5 days of the month.15

Some preventive strategies are “nonspecific”

When treatment of acute MM is inadequate, management shifts toward prevention. Options include nonspecific (those that do not address the hormonal trigger) and specific (hormonal) strategies. Nonspecific strategies rely on the predictable onset of MM for proper timing of the therapeutic intervention; therefore, women who have irregular cycles are not good candidates for this approach. The presence of comorbid conditions such as dysmenorrhea, menometrorrhagia, and endometriosis may argue for early adoption of specific strategies that improve both conditions at once.

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