By Sarah Bradley
It had been happening every two weeks, like clockwork, for five months.
The worst attacks involved sharp, blinding pain that seared up the back of my head, along with nausea, fatigue, and light sensitivity. It would go on for hours; sometimes the only solution was sleep.
Migraines and other migraine-related symptoms plagued me daily. The more mild episodes were less painful, but still frustratingly stubborn: migraines arriving in the form of aching sinus headaches not cured by any over-the-counter (OTC) pain reliever or decongestant.
Then, for two weeks, I would have virtually no symptoms—until it started all over again.
After several months, I finally opened up my calendar, determined to figure out what was triggering them. As I scrutinized the dates of my migraine episodes, I started to connect the dots. Why did I have symptoms every day for those particular weeks in December, and then not again until January? And why did that pattern repeat itself every month?
That’s when it clicked: My period was the trigger.
My husband and I practice fertility awareness for our family planning needs, so I know the ins and outs of my cycle like the back of my hand. Whenever my period started, so did the migraines; whenever I ovulated, they disappeared. I talked to my primary physician, who agreed that my migraines weren’t random—they were menstrual.
WHAT ARE MENSTRUAL MIGRAINES?
Migraines triggered by hormone fluctuations in a woman’s monthly cycle are considered menstrually-related migraines (MRM), which the National Institutes of Health classifies as any migraine episode that occurs up to two days before the onset of a period and three days after, for at least two out of three periods.
“Some studies have identified that about 70 percent of women with migraine have MRM, while others have shown more conservative numbers of 40 to 50 percent,” says Jelena Pavlovic, M.D., Ph.D., attending neurologist and assistant professor at New York’s Montefiore Health System and American Headache Society member. “But menstrual migraine is often underreported and underdiagnosed because, in many women, the attacks often start prior to the onset of bleeding and/or do not last the whole menstrual period.”
Why does menstruation have the power to trigger migraines in so many women? Blame estrogen.
“Menstrual migraine is commonly thought to be ‘triggered’ by the late-luteal phase [or premenstrual] drop in estrogen,” says Pavlovic.
Identifying my migraines as menstrually-related was the most valuable thing I’ve done.
Since my migraines start with menstruationbut continue for nearly two weeks, there are likely other common triggers causing me to experience migraines during a time when I’m particularly susceptible to them (estrogen levels surge around ovulation, which likely explains why I find relief at that point in my cycle).
But menstruation remains my initial trigger—which means it has also been the key to figuring out how best to treat my migraines.
MENSTRUAL MIGRAINE TREATMENTS
There are no specific treatment options identified solely for MRM, but a combination of traditional migraine treatments, alternative therapies, and hormone-related strategies can be effective.
- Nonsteroidal anti-inflammatory (NSAID) drugs
OTC or prescribed NSAIDs, like ibuprofen (Advil, Motrin) and naproxen (Aleve), can be a first line of defense in treating migraines, though they may not quite do the trick. A 2013 review of clinical trials showed that the effectiveness of naproxen often depends on the severity of the migraines and whether it’s being used in conjunction with other medications.
Triptans are a type of drug that work to reduce the swelling of blood vessels in the head, are one of the more popular prescription medication options for migraines.
“A long-acting triptan, such as naratriptanor frovatriptan, may be used preventively, beginning about a day before the expected onset of symptoms and continuing for the usual length of symptoms,” says Pavlovic. “For this method to work it is important that a patient have a regular menstrual cycle and keep a good headache diary, so she can calculate when her migraines are likely to start and can make a plan to avoid other triggers.”
- Transdermal estradiol
For women who don’t find much relief with non-hormone treatments, transdermal estradiol (like in an estrogen patch) can help. Since MRM is linked to low levels of estrogen, raising those levels around the time that patients normally experience migraines is a potential solution.
“[Transdermal estradiol] can be applied for a week, starting about five to seven days premenstrually and continuing through the second day of bleeding,” says Pavlovic. Again, this method is preventative, so it helps to be able to track and predict your menstruation.
- Caffeine (Maybe)
It's no coincidence that the OTC painkiller Excedrin Migraine includes a combination of aspirin, acetaminophen, and caffeine—according to the Cleveland Clinic, the stimulant is sometimes used as a treatment for migraines, though it can also contribute to migraines and cause rebound headaches.
Holly Lucille, N.D., R.N., a private-practice naturopathic physician and educator, says caffeine works on multiple levels to assist with migraines: “It’s often considered a taxi that moves pain-relief ingredients quickly through the bloodstream, but it’s actually a pain-reliever in its own right.”
However, a 2016 study in The Journal of Headache and Pain suggests that the discontinuation of caffeine intake gives migraine sufferers better results. Pavlovic agrees. "In those who have frequent headaches, daily caffeine intake can worsen them and lead to more headaches,” she says. “They are advised to limit, if not completely cut out, caffeine from their diet."
Magnesium is pretty widely accepted as a potential remedy.“Magnesium may be in short supply in those who suffer from migraines, acting as a co-conspirator with hormone fluctuations in causing the condition,” says Lucille.
"Magnesium has been used primarily as a preventive agent for menstrual migraine," adds Pavlovic. "In practice, we frequently recommend 400 milligrams of magnesium oxide daily, or at least during seven to 10 days around menstruation."
The American Migraine Foundation also acknowledges that magnesium is a reliable preventative strategy with an “excellent safety profile.” (Just remember to consult a physician before taking any dietary supplements.)
'I'M STILL FIGURING OUT WHAT WORKS FOR MY MIGRAINES'
It’s been more than a year of trial and error so far.
I know that a large glass of water followed by a cup of caffeinated coffee first thing in the morning does wonders to stave off many of my symptoms. If a migraine develops anyway, I take a triptan; if I wake up with one already in progress, Excedrin Migraine is the fastest and most reliable option.
I’ve also started taking a daily dose of chelated magnesium, though I’ve struggled to find an effective amount that doesn’t upset my stomach.
But ultimately, identifying my migraines as menstrually-related was the most valuable thing I’ve done. I’m not at the mercy of my migraines as much as I was before: I know what’s causing them, when they’ll start, and (thankfully) when they’ll end.
For a condition where prevention remains one of the most useful treatment strategies, that knowledge is power.