Menstrual migraine is a one of the headache types in women occurs due to decrease in estrogen level during menstruation cycle. 

Migraines occur before or during menstruation period. Estrogen connection with brain chemistry affects serotonin and migraine development. 

Menstrual-Related migraines symptoms happen two days before and three days into period. 

Pure menstrual migraines arise only during menstruation and no other times in cycle. 

Menstrual migraines show symptoms including throbbing pain, nausea, and vomiting. 

Timing of menstrual headache are: 

Menstrual-Related Migraines 

Pure Menstrual Migraines 

50% to 60% women with migraines report menstrual cycle association. Migraines affect 12% of population and it is more observed in women than men.  

Migraines peak in women aged 30 to 40 years old with menstrual headaches during perimenopause. 

Up to 41% of all women experience a migraine episode in the age of 50. 

Migraine is less common in African Americans and Asian Americans compared to whites. 

Estrogen has an influence on serotonin receptors, cerebral vessels, and dopaminergic receptors sensitivity. 

Activation of pain pathways in brain amplifies pain signals to cranial blood vessels. It attributes the aura to ischemia from vasoconstriction and headache to vasodilation and nerve activation.  

The neurovascular theory explains that migraine is caused by neural and vascular events, with neuronal hyperexcitability in the cerebral cortex, particularly the occipital cortex.  

Most migraine headache patients without aura show normal regional cerebral blood flow. 

Low estrogen in late secretory phase of menstrual cycle decreases serotonin that increases CGRP and substance P from trigeminal nerves. 

During menstruation, meningeal nociception intensifies from increased blood-brain barrier permeability and reduced endogenous opioid activity. 

Familial hemiplegic migraine is a rare migraine type with aura accompanied by hemiplegia and potentially linked to cerebellar ataxia at the 19p locus. 

Migraine substances cause vessel dilation, sensory sensitization in brain, and general migraine pathophysiology.

Menstrual-related headaches in women have a good prognosis and respond well to therapy. 

Patient with irregular cycles are not good candidates for hormone-directed therapy. 

Migraine patients over 45 years, especially women, are at higher risk of ischemic stroke.  

Women with migraines have a 2.5-fold risk of subclinical cerebellar stroke with aura and frequent headaches increasing risk. 

To assess menstrual migraine information includes recent symptoms, pattern of menstrual cycle and medical history of patient. 

Head and Neck Examination 

Eye Examination 

Neurological Examination 

Menstrual migraine achieves its peak intensity within hours of starting and shows causes such as pain, nausea, vomiting, and extreme sensitivity to light, sound, and smells. 

Treatment choice for each patient based on attack severity, associated symptoms, comorbidities, and treatment response. 

IV metoclopramide equals triptans for acute migraine treatment in emergency rooms. 

Preventive treatment, given without a headache, reduces migraine frequency and severity to abortive therapy during acute attacks. 

Dihydroergotamine is used for severe chronic migraine headaches or status migrainosus due to its properties. 

ED care for migraine includes specialized medications and pain relief, with narcotics administered in emergency settings. 

CGRP modulation in migraine pain transmission. Novel CGRP antagonists offer acute treatment for inadequate response.  

Patients advised to avoid migraine factors which triggers and keep a daily diary to track headaches for effective monitoring of the disease. 

Opioids are not recommended for treating MRH due to CNS changes. They cause increased facilitation from the rostral ventromedial medulla and excitatory neurotransmission at the dorsal horn. 

Neurology

Make quiet area for patients and wear earplugs and headphones to block noise. 

Maintain comfortable humidity levels with humidifiers or dehumidifiers to prevent triggers from overly dry and moist air. 

Optimize workspace setup with proper chair, desk, and monitor for comfort.  

Keep consistent sleep routine. Create comfortable sleep space with good mattress, pillows, and minimize noise and light for restful sleep. 

Encourage patient to rest in quiet and comfortable environment at home to reduce the pain. 

Proper awareness about menstrual migraine should be provided and its related causes with management strategies. 

Appointments with a neurologist and preventing recurrence of disorder is an ongoing life-long effort. 

Neurology

Naratriptan:  

It acts slowly and stays up to 24 hours, with low headache recurrence. 

Zolmitriptan: 

It reduces migraine inflammation with 62% efficacy at 2 hours and 75 to 78% at 4 hours. 

Almotriptan: 

It constricts vessels, which inhibits neuropeptide release thus reducing pain transmission. 

Neurology

Ergotamine: 

It partially inhibits specific receptors, which causes vasoconstriction in blood vessels. 

Dihydroergotamine: 

It stimulates smooth muscle in blood vessels which blocks alpha-adrenergic receptors. 

Neurology

Ibuprofen:  

It reduces enzyme COX inhibitor activity which causes inhibitory effects on inflammation and pain. 

Ketoprofen: 

It inhibits COX-1 and COX-2 inhibitors that reduce mild to moderate pain. 

Neurology

Erenumab: 

It binds to CGRP receptor and is used for preventive treatment of migraines in adults. 

Neurology

Valproic acid:  

It inhibits migraine-related processes in the cortex, perivascular region, and trigeminal nucleus. 

Neurology

Botox is injected around the head and neck to block pain transmission chemicals, which prevent activation of pain pathways. 

In nerve block procedure, local anesthetics and steroids injected near nerves to block headache pain signals. 

Neurology

In initial treatment phase use of acute and preventive management therapies to reduce the severity and duration of the attack in patient. 

Pharmacologic therapy is effective in the treatment phase as it includes use of triptan therapy, ergot derivatives, NSAID, and anticonvulsants. 

In supportive care and management phase, patients should receive required attention such as lifestyle modification and therapies. 

The regular follow-up visits with the neurologist are scheduled to check the improvement of patients along with treatment response.