Are Menstrual and Nonmenstrual Migraine Attacks Different?

Migraine is the second most common headache condition next to tension-type headache. Up to one fourth of all women have migraine, and 20% of them experience migraine without aura attack in at least two thirds of their menstrual cycles. The current literature is analyzed in response to the question of whether menstrual and nonmenstrual migraine attacks are different. The different studies provide conflicting results, so it is not possible to answer the question firmly. Future studies should be based on the general population. Collection of both prospective and retrospective data is warranted, and headache diagnosis base on interviews by physicians with interest in headache are more precise than lay interviews or questionnaires

Effect of exogenous estrogens and progestogens on the course of migraine during reproductive age

We systematically reviewed data about the effect of exogenous estrogens and progestogens on the course of migraine during reproductive age. Thereafter a consensus procedure among international experts was undertaken to develop statements to support clinical decision making, in terms of possible effects on migraine course of exogenous estrogens and progestogens and on possible treatment of headache associated with the use or with the withdrawal of hormones. Overall, quality of current evidence is low. Recommendations are provided for all the compounds with available evidence including the conventional 21/7 combined hormonal contraception, the desogestrel only oral pill, combined oral contraceptives with shortened pill-free interval, combined oral contraceptives with estradiol supplementation during the pill-free interval, extended regimen of combined hormonal contraceptive with pill or patch, combined hormonal contraceptive vaginal ring, transdermal estradiol supplementation with gel, transdermal estradiol supplementation with patch, subcutaneous estrogen implant with cyclical oral progestogen. As the quality of available data is poor, further research is needed on this topic to improve the knowledge about the use of estrogens and progestogens in women with migraine. There is a need for better management of headaches related to the use of hormones or their withdrawal

Menstrual migraine in the general population – prevalence, clinical characteristics and classification

During the reproductive years, migraine is two to three times more prevalent in women compared to men. This sex difference may, at least in part, be due to the cyclic changes in female sex hormones and a subset of female migraineurs recognizes menstruation as the most important trigger of attacks. In 2004, formal diagnostic criteria for menstrual migraine were published in the appendix of the International Classification of Headache Disorders 2nd edition (ICHD II). Menstrual migraine was defined as attacks of migraine without aura occurring on the days centering on the first day of the menstrual bleeding, i.e. day -2 to +3, in at least two out of three consecutive menstrual cycles. In the revised version from 2013 (ICHD III beta), a requirement of prospective headache diaries over three menstrual cycles was added in order to confirm the diagnosis. This was based on previous studies reporting that women tend to over report menstrual migraine by self-assessment. The diagnosis is still placed in the appendix because it is considered as insufficiently validated. Most previous studies on menstrual migraine are conducted in clinic populations, and no studies have previously used the ICHD criteria in the general population. The purpose of the present study was to investigate prevalence and characteristics in menstrual migraine in the general population. This thesis is based on four original research papers from a population-based study on menstrual migraine. The participants were recruited by questionnaires mailed to 5000 women aged 30-34 years from the general population and women with self-reported menstrual migraine were invited to a clinical interview and examination at Akershus University Hospital. Subsequently, the women were instructed to complete a headache- and menstruation diary for three consecutive menstrual cycles. Among 308 eligible women who self-reported migraine in at least half of their menstruations by questionnaire, 237 (77%) participated in the interview. The lifetime prevalence of menstrual migraine was 17.6% among female migraineurs and 6.1% among all women. Only one out of seven women experienced migraine exclusively in relation to menstruation. The headache diary was returned by 123 (52%) women. A substantial agreement between menstrual migraine diagnoses given by interview versus those given by diaries was found (Kappa 0.62). The characteristics of menstrual and non-menstrual attacks of migraine without aura were compared among the 56 women with a prospectively confirmed diary-diagnosis of menstrual migraine. In these women, menstrual attacks lasted on average nearly 11 hours longer, were significantly more often associated with severe nausea, and were on average treated with 1.4 more doses of symptomatic drugs than non-menstrual attacks. In contrast, no differences between menstrual and non-menstrual attacks were found among the 25 women who had migraine without aura but who did not fulfil the diagnostic criteria for menstrual migraine. The clinical interview included questions about the course of migraine during use of current hormonal contraception. Women with a history of menstrual migraine who developed contraception-induced amenorrhoea were more likely to report a reduction in their total migraine frequency compared women with a history of menstrual migraine who were not amenorrhoeic. Conclusion: Menstrual migraine occurs in about one fifth of female migraineurs in the general population and in these women, menstrual attacks are associated with more severe symptomatology than non-menstrual attacks. The diagnosis can be made by a physician’s semi-structured interview and diaries should only be required in specific cases. Hormonal contraception that induces amenorrhoea might be beneficial in women with menstrual migraine

Menstrual versus non-menstrual attacks of migraine without aura in women with and without menstrual migraine

Objective The objective of this article is to compare clinical characteristics of menstrual and non-menstrual attacks of migraine without aura (MO), prospectively recorded in a headache diary, by women with and without a diagnosis of menstrual migraine without aura (MM) according to the International Classification of Headache Disorders (ICHD). Material and methods A total of 237 women from the general population with self-reported migraine in ≥50% of their menstrual periods were interviewed and classified by a physician according to the criteria of the ICHD II. Subsequently, all participants were instructed to complete a prospective headache diary for at least three menstrual cycles. Clinical characteristics of menstrual and non-menstrual attacks of MO were compared by a regression model for repeated measurements. Results In total, 123 (52%) women completed the diary. In the 56 women who were prospectively diagnosed with MM by diary, the menstrual MO-attacks were longer (on average 10.65 hours, 99% CI 3.17–18.12) and more frequently accompanied by severe nausea (OR 2.14, 99% CI 1.20–3.84) than non-menstrual MO-attacks. No significant differences between menstrual and non-menstrual MO-attacks were found among women with MO, but no MM. Conclusion In women from the general population, menstrual MO-attacks differ from non-menstrual attacks only in women who fulfil the ICHD criteria for MM

Effect of exogenous estrogens and progestogens on the course of migraine during reproductive age: a consensus statement by the European Headache Federation (EHF) and the European Society of Contraception and Reproductive Health (ESCRH)

We systematically reviewed data about the effect of exogenous estrogens and progestogens on the course of migraine during reproductive age. Thereafter a consensus procedure among international experts was undertaken to develop statements to support clinical decision making, in terms of possible effects on migraine course of exogenous estrogens and progestogens and on possible treatment of headache associated with the use or with the withdrawal of hormones. Overall, quality of current evidence is low. Recommendations are provided for all the compounds with available evidence including the conventional 21/7 combined hormonal contraception, the desogestrel only oral pill, combined oral contraceptives with shortened pill-free interval, combined oral contraceptives with estradiol supplementation during the pill-free interval, extended regimen of combined hormonal contraceptive with pill or patch, combined hormonal contraceptive vaginal ring, transdermal estradiol supplementation with gel, transdermal estradiol supplementation with patch, subcutaneous estrogen implant with cyclical oral progestogen. As the quality of available data is poor, further research is needed on this topic to improve the knowledge about the use of estrogens and progestogens in women with migraine. There is a need for better management of headaches related to the use of hormones or their withdrawal