In the United States, 1.4 percent of all visits to office-based physicians is due to headache,which represents approximately 12 million physician visits in one year. According to recent studies, 8.7 million females and 2.6 million males in the U.S. experience migraine. Only about one-third of female headache sufferers have ever consulted a physician for their headache problems. The headache attacks greatly impact on the ability of women to work and pursue everyday life activities.

Migraine onset typically occurs about the time of puberty, and its prevalence reaches a peak before menopause, and the frequency decreases thereafter. Headache ratio between females and males at age 20 is about 2 to 1, and about 3.3 to 1 between ages 42 to 44. It decreases to about 2.5 to 1 by age 70. This pattern underscores the link between hormones and headaches in women. In this section, we will review topics of interest to female headache sufferers starting with the treatment of menstrual migraine.

Menstrual Migraine
Up to 70 percent of female migraine sufferers describe a relationship to their periods. The attacks occur either before, during, or immediately after their flow. Also, some women will complain of headaches at the time of ovulation. These menstrual headaches are related to fluctuations in hormone levels which regulate the menstrual cycle. All of the events in the normal female life cycle that are associated with varying sex hormone levels (estrogen, progesterone) menarche (initial onset of periods), pregnancy, birth control pill use, menopause, and hormone replacement therapy may cause a change in the frequency, severity, duration, and complications of headaches.

Most female migraine patients report a decrease or remission of their headaches after the first trimester of pregnancy.

Treatment
For those patients complaining of headaches at the time of their periods, treatment can be complicated. Remedies that may be beneficial at other times of the month will be unsuccessful at period time. If the individual only experiences headaches during her periods, she may be reluctant to take medications the remainder of the month which could prevent the attacks.

In menstrual migraine, the agents of choice are the nonsteroidal anti-inflammatory agents (NSAIDs). This group of drugs includes over-the-counter agents, such as ibuprofen (Advil®, Nuprin®, Motrin IB®), naproxen sodium (Aleve®), and ketoprofen (Orudis®). It is essential that the agents are started 2 to 3 days prior to the onset of the period, and continued through the flow. The NSAIDs prevent clumping of the platelets, believed to be a factor in migraine, and swelling. Because these drugs are being used for a limited time, the usual complaints of stomach distress are minimal. The prescription NSAIDs most often used for menstrual migraine include fenoprofen calcium (Nalfon®), naproxen (Naprosyn®), nabumetone (Relafen®), and ketorolac (Toradol®). If one NSAID is ineffective, another type of NSAID should be tried.

For those whose headaches do not respond to the NSAIDs, small doses of ergotamine agents may be used. These ergotamine agents have been used for decades in migraine treatment. These agents must be prescribed by a physician. When used for menstrual headache, the agent can be at bedtime or twice daily. One of these drugs, Bellergal-S®, contains ergotamine as well as phenobarbital and belladonna alkaloids, and is administered 2 to 3 times a day, starting 3 days before and continuing through the menstrual period. Other agents used in menstrual migraine prevention include methylergonovine maleate (Ergonovine®) and dihydroergotamine maleate (D.H.E.-45®), and methysergide (Sansert®). Estrogen administered via transdermal patches, applied to the skin immediately before menstruation, may be effective.

If you have any specific questions or would like information on menstrual headaches or other hormonal headaches, please contact the Diamond Headache Clinic: clinic@diamondheadache.com or 1-800-HEADACHE.