Why are menstrual migraines heavier

Menstrual migraines - falling estrogen levels are often the cause

About a third of all women of childbearing age plagued by migraine suffer at least partially from menstrual attacks. They typically occur shortly before the menstrual period or up to the third day of bleeding, and more rarely around the time of ovulation. These cycle phases are hormonally accompanied by a drop in the estrogen level, report the Freiburg neurologist Dr. Anna Gorsler and Professor Holger Kaube (NeuroTransmitter 7-8, 2008, 32).

There is no specific therapy for women with hormone-related headaches. Those affected should be treated according to the usual recommendations for migraine therapy, advise the neurologists. Almost all of the triptans have been tried and tested and are effective. Since menstrual migraine attacks often last longer, repeated triptan doses may be necessary.

No estrogens in smokers with migraines!

In terms of prophylaxis, it should be noted that conventional migraine prophylaxis with beta-receptor blockers, flunarizine or topiramate does not work in menstrual migraines. Since it is triggered by a drop in estrogen, there are hormonal influences here. The benefits and possible risks of estrogen administration, such as an increased risk of breast cancer and thrombosis, should be weighed. Estrogens are absolutely contraindicated in smokers with migraines due to the significantly increased risk of a stroke.

For women with a regular cycle, short-term prophylaxis with an NSAID such as naproxen is recommended. The intake of 500 to 1000 mg daily should begin two days before the expected menstruation and last until the third day of bleeding. To protect against possible stomach problems, the combination with a proton pump inhibitor is appropriate. If there is no effect, long-acting triptans such as frovatriptan and naratriptan can also be given prophylactically two days before the expected menstruation and up to the third day of bleeding. The third variant of short-term prophylaxis is the application of estradiol as a gel or plaster.

Long-term hormonal prophylaxis should be considered for women who have severely debilitating and long-lasting migraine attacks associated with menstruation. The aim is to prevent fluctuations or a drop in estrogen levels. A monophasic combination pill with a medium dose of estrogen is suitable for this. Women have had positive experiences in studies with the continuous intake of an estrogen-progestogen combination for 84 or even 168 days with a subsequent seven-day pill break. The migraine attacks did not occur until the withdrawal bleeding after discontinuation of the pill, not as usual monthly. From a medical point of view, there is nothing to be said against suppressing menstruation for such a long period of time. But there could be intermenstrual bleeding.

Usually fewer migraine attacks after menopause

The frequency of migraine attacks decreases significantly during pregnancy and after menopause. However, attacks can also increase during menopause. The same applies to therapy here as to menstruation-associated attacks: Normally high and even estrogen levels are aimed for.

In the case of severe hormone-related impairment due to migraines, induction of a "chemical menopause" with administration of hypothalamic hormones (gonadotropin-releasing hormone analogs) with simultaneous estrogen and progestin substitution should also be considered in the premenopausal phase

If migraine-like headaches occur daily after oral estrogen substitution, this is an indication that the hormones are rapidly metabolized in the liver (almost metabolizer). Then transdermal or vaginal dosage forms make sense. There is no evidence of an increased risk of stroke with hormone replacement therapy after menopause.

NSAIDs start two days before the menstrual period.