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Hormonal Interventions for Menstrual Migraines
Kathleen J. Chavanu, Pharm.D., Dannielle C.
O’Donnell, Pharm.D.
Posted November 2002  
Pharmacotherapy Vol. 22; 1455-1456

Menstrual migraines are a treatment challenge for both the migraineur and the health care professional. Although some women with menstrual migraines may respond to acute and preventive therapies for nonmenstrual migraines, others continue to suffer from refractory menstrual migraines. These women may respond to hormonal interventions, which may reduce the frequency of menstrual migraines; thereby lessening the need for abortive migraine therapies, decreasing migraine-related disability, and improving quality of life. Menstrual migraines have a distinct pathophysiology that differs from menstrual-related migraines. Published studies have shed light on the effectiveness of a variety of hormonal interventions, including oral contraceptives, which may be administered with an extended-dosing strategy; estrogen replacement therapy; selective estrogen receptor modifiers; danazol; and leuprolide.

Conclusion:   Menstrual migraines may be difficult to recognize without a patient diary that charts headaches and menstruation. These migraines are also a challenge to manage with traditional abortive and prophylactic migraine therapies, and many approaches to trigger migraine identification and avoidance do not work. Once the appropriate diagnosis of menstrual migraine is made, the health care professional should evaluate the timing and duration of pain and associated symptoms. Abortive drugs should be prescribed and adjusted to individual responses. First-line prophylactic agents may consist of traditional migraine prophylactic therapies, a therapeutic trial of extended-duration, low-dose oral contraceptives, or estrogen transdermal patches that are applied before the anticipated onset of menses, depending on patient factors. If patients are unresponsive to first-line agents, tamoxifen or danazol may be appropriate. An option of last resort is the administration of a gonadotropin-releasing hormone agonist, which should be reserved for women with menstrual migraines refractory to both hormonal therapy and treatments for nonmenstrual migraines.