Menstrual Migraine

1. MENSTRUAL
MIGRAINE
ADE WIJAYA, MD
AUGUST, 2017

2. “A specific condition where the timing of
attacks is linked to the menstrual cycle”
MENSTRUAL MIGRAINE

3. Outline:
• Normal menstrual cycles
• Migraine diagnostic criteria
• Menstrual migraine:
- Epidemiology
- Pathophysiology
- Management
• Summary

4. NORMAL
MENSTRUAL
CYCLE

5. IHS Diagnostic Criteria of Migraine

6. International Classification of Headache Disorders II criteria for menstrual migraine
(Headache Classification Subcommittee of the International Headache Society, 2004)

7. Epidemiology
60 % migraineurs reported increased frequency related to menstruation
7-14 % migraneurs have menstruation as the only trigger of their migraines
Migraines is more severe in menstrual period
Kornstein SG, Parker AJ. Menstrual migraines:Etiology, treatment, and relationship to premenstrual syndrome. Curr Opin Obstet Gynecol. 1997;9:154-159.

8. Pathophysiology
ESTROGEN
WITHDRAWAL
Loder, E. W. (2006). Menstrual migraine: pathophysiology, diagnosis, and impact. Headache:
The Journal of Head and Face Pain, 46(s2).

9. Pathophysiology
 estrogen   serotonin production,  serotonin reuptake and elimination
 estrogen  greater pain tolerance, acts as endogenous opioid, regulate galanine and
neuropeptide Y involved in nociception
 estrogen during pregnancy  pregnant women have better pain tolerance
1. Martin VT, Behbehani M. Ovarian hormones and migraine headache: Understanding mechanisms and pathogenesis—part I. Headache. 2006;46:3-23.
2. Silberstein SD, Elkind AH, Schreiber C, Keywood C. A randomized trial of frovatriptan for the intermittent prevention of menstrual migraine. Neurology. 2004;63:261-269.
3. Dawson-Basoa MB, Gintzler AR. 17-β-estradiol and progesterone modulate an intrinsic opioid analgesic system. Brain Res. 1993;601:241-245.
4. Puri V, Cui L, Liverman CS, Roby KF, Klein RM, Welch KM, Berman NE. Ovarian steroids regulate neuropeptides in the trigeminal ganglion. Neuropeptides. 2005;39:409-417.
5. Cahill CA. Beta-endorphin levels during pregnancy and labor: A role in pain modulation? Nurs Res. 1989;38:200-203.

10. Neurotransmitters in Pain
Millan M.J. Descending control of pain. Progress in
Neurobiology, 2002, 66, 6, 355–474.

11. Other Theories
1. Opioid System
2. Hypothalamic–Pituitary–Adrenal (HPA) System
3. Adrenergic System
4. Serotonergic System
5. Prolactin
6. Melatonin
7. Nitric Oxides
8. Prostaglandins
(Fioroni et al., 1995; R.E. Nappi et al., 1999)

12. Management
ENHANCED ACUTE TREATMENT:
1. Triptans (ORAL) + NSAIDs
2. Sumatriptan / dehidroergotamine injection
3. Nasal triptans
MINI-PREVENTION: + triptans as acute treatment
1. Naproxen 2 x 550 mg (or other NSAIDs) during approximate menstrual periods
2. Estrogen pills
3. Triptans
4. Magnesium started at day 15 of menstrual cycle until menstruation period
CONTINUOUS PREVENTION:
Estrogen: pills or vaginal ring Headache: The Journal of Head and Face Pain © 2013 American Headache
Society Published by John Wiley & Sons, Inc. doi: 10.1111/head.12279

13. Summary
Migraines that happen during menstruation or related to menstrual cycle
Frequent among migraneurs and usually more severe headache
Fall of estrogen level related
Treatment strategies including:
enhanced acute treatments, mini-prevention, and continuous prevention

14. THANK YOU