Because women account for more than half of all migraine sufferers, it's probably not hard to believe that one of the most commonly reported migraine triggers is menstruation. Whether it's right before a period or somewhere in the middle, for some women that "time-of-the-month" will instigate a menstrual migraine like clockwork. Though several effective treatments are available to fight most migraines, menstrual migraines are unique in that they may also be responsive to birth control pills. But before you resolve to go on "the pill" to treat your menstrual migraines there are many important factors to consider.
What are menstrual migraines?
Menstrual migraines are painful attacks that tend to last longer than other types of migraines . They can strike anywhere from two days before to three days after the start of menstrual flow. While scientists are not completely sure why these attacks occur there is strong evidence that estrogen, a hormone that helps regulate the menstrual cycle, is involved. One theory is that the drop in estrogen that occurs right before menstruation excites the brain regions that are involved in migraine and triggers an attack. Interestingly, it's not the actual estrogen levels that are believed to trigger migraines but rather the drop or change in estrogen that triggers the migraine. While some women experience pure menstrual migraines, which are attacks that only occur during menstruation, most women suffer from menstrual-associated migraines, which are attacks that occur during menstruation as well as other times of the month.
How is menstrual migraine treated?
Menstrual migraine can be treated with the same approaches used to treat other types of migraines. Anti-inflammatory painkillers like naproxen or ibuprofen, anti-nausea medicines, and triptans can all be effective. For some women, taking oral contraceptives or a contraceptive combined with estrogen can reduce the frequency of menstrual migraines. For estrogen based pills the thought is that the pill will provide enough extra estrogen to "top off" your current levels. Therefore, any estrogen drop that occurs before the start of the menstrual cycle won't be significant enough to trigger an attack.
What will my doctor need to know to determine if birth control pills are right for me?
While the pill has proven to be a convenient and effective form of contraception for many women, keep in mind that they may not always be the bestmethod to treat your migraine. It is important that you consult with a neurologist first, to determine if traditional migraine treatments such as over-the-counter or prescription painkillers may offer the relief you need. Birth control pills solely for migraine treatment are most commonly used by women who cannot get pain relief from some of the more common migraine treatments.
Because there may be serious side effects involved in oral contraceptive use, you will need to work with a gynecologist to determine if you might find relief by going on the pill. She will want to evaluate factors such as your age, smoking habits and cholesterol level, as well as any history of hypertension, vascular disorders, pulmonary embolism or stroke, before determining if an oral contraceptive is right for you. She will also want to determine if your migraine is truly menstrual-associated, and not just coincidental. You may be asked to keep a log or diary of your attacks for several months - noting each time you experience a migraine and the dates of your menstrual flow.
If my doctor approves, can I take the birth control pills in the usual way?
First let's understand how birth control pills are usually taken. Most birth control pills are prescribed as monthly 28-day or 21-day packs. In both packs, there are 21 pills that contain an active hormone that prevent pregnancy. In the 21-day pack, pills are taken daily for three weeks and the following week no pills are taken while menstruation occurs. The additional seven pills that come in the 28-day pack are reminder pills called placebos - they are hormone-free and will also coincide with menstruation.
Some doctors will allow you to take a monthly pack of pills continuously for 3 months, 6 months or even up to 1 year, to keep your estrogen levels constant. This means skipping the placebo pills if you have a 28-day pack, or continuously taking them if you have 21 day packs. Fewer bleeding episodes per year will equal fewer migraines. In some cases, estrogen supplements may be prescribed during the pill-free/placebo period. Though some continuous birth control methods can help prevent menstrual migraines, it should be noted that many people suffer attacks immediately after the pills are stopped, or during pill-free points of the month.
Birth control pills are generally not recommended for women who suffer menstrual migraines with aura (an unpleasant occurrence in some migraine sufferers that may cause vision problems, numbness, or difficulty speaking). Patients who suffer migraine with aura may be at increased risk of stroke and are therefore poor candidates for most birth control pills. Under some circumstances a doctor may approve a progesterone-based contraceptive that prevents ovulation in these patients. If ovulation is prevented, then there is no drop in estrogen levels, and a migraine is less likely to be triggered.
It's important to remember that not all cases of menstrual migraine can be cured. But if headaches are disrupting your daily life, don't give up on the search for treatment. Work with your neurologist, gynecologist, and general practicioner to find a solution that can work for you.
The National Pain Foundation. Menstrual Migraine. Accessed: January 2012.
US Dept of Health and Human Services. Women's Health. Migraine Facts. Accessed: January 2012.
MacGregor EA. Prevention and treatment of menstrual migraine. Drugs. 2010 Oct 1;70(14):1799-818