Article by Dr Manasa S, B.A.M.S
Menstrual Related Headaches (MRH), commonly known as menstrual migraines, are a prevalent form of headaches predominantly afflicting women.
These headaches are closely linked to hormonal fluctuations, particularly a decline in oestrogen levels during the menstrual cycle. Therefore, they are also known by the other name, hormonal headaches.
Epidemiologically, migraines affect approximately 12% of the general population. It is observed that there is a higher rate of prevalence among women especially during their menstrual cycles, pregnancy, perimenopause and during the intake of combined oral contraceptive pills. Peak prevalence of migraine in women is noted between the early 30s to early 40s and menstrual related headache is seen in perimenopausal women. Typically, the menstrual related headache starts from two days before menstruation onset to the third day of menstrual bleeding.
Hormones are the “chemical messengers” secreted by the endocrine glands which play a pivotal role in many functions of the body. Oestrogen and progesterone are the two important hormones secreted by the ovaries in women. Feminine physical features, onset of puberty and reproduction are under the influence of oestrogen. Oestrogen also controls the menstrual cycle, protects bone health and has a role in the health of the heart, skin, bones and other tissues. The levels of oestrogen change during the entire phase of reproductive life of a woman from menarche to menopause. The amount of oestrogen is high during the mid of the cycle, drops immediately before the onset of menstruation and they hit very low during perimenopause and stops secreting during and after menopause. This drop in the levels of oestrogen is the primary reason for hormonal headaches.
Understanding the pathophysiology of MRH reveals the pivotal role of oestrogen in modulating serotonin and glutamate systems within the central nervous system (CNS). Diminished oestrogen levels, particularly during the late secretory phase of the menstrual cycle, precipitate chain of events involving neurotransmitters like serotonin and neuropeptides such as calcitonin gene-related peptide (CGRP) and substance P. These biochemical changes induce vasodilation of intracerebral vessels and sensitization of trigeminal nerves, culminating in heightened cranial nociception.
Assessment of familial predisposition and consideration of genetic variances in protein channels and receptors associated with migraine pathogenesis are vital in clinical evaluation. Additionally, factors such as hormonal contraception usage and oestrogen dosage significantly influence MRH susceptibility.
Causes
Factors Affecting Headaches:
– Pregnancy: Oestrogen levels rise during pregnancy, leading to relief for many women from hormonal headaches. However, some may experience migraines for the first time during early pregnancy, with relief typically following the first trimester. After childbirth, oestrogen levels drop rapidly.
– Oral Contraceptives and Hormone Replacement Therapy: These can cause fluctuations in hormone levels. Women on birth control pills may experience migraines during the hormone-free week of their cycle.
– Menstrual Cycle: Oestrogen and progesterone levels drop just before menstruation, often triggering headaches.
– Perimenopause and Menopause: Fluctuating hormone levels during perimenopause may increase headache frequency. While many women see improvement in migraines during menopause, some may experience worsening symptoms, possibly due to hormone replacement therapies.
Other Contributing Factors:
– Genetics: Chronic migraines may have a genetic component, with individuals experiencing a combination of triggers.
– Dietary Factors: Certain foods and beverages, such as aged cheeses, processed meats, and alcoholic beverages like red wine, can trigger headaches.
– Sleep Pattern: Both too much and too little sleep can contribute to headaches.
– Environmental Factors: Intense lights, sounds, or smells, as well as severe weather changes, can trigger migraines.
– Stress: Emotional or physical stress can exacerbate headaches.
– Caffeine: Excessive consumption or withdrawal from caffeine can lead to headaches.
– Food Additives: Substances like monosodium glutamate (MSG) and artificial sweeteners may trigger migraines in some individuals.
– Soy Products: Some people may be sensitive to soy products, which can contribute to headaches.
Triggering factors
– Birth control polls
– Hormonal replacement therapy for menopause
Symptoms
– Pre-headache aura (not everyone experiences this symptom)
– Pulsating pain on one side of the head
– Reduced appetite
– Heightened sensitivity to light, sound, and odours
– Experience of chills
– Increased sweating
– Pallid complexion
– Tender or delicate scalp
– Abdominal discomfort
– Vision blurring
– Feelings of dizziness
– Headache
– Decreased urine output
– Impaired coordination
– Heightened appetite
– Desire for chocolate, salt, or alcohol cravings
Diagnostic criteria
Diagnostic criteria as outlined in the International Classification of Headache Disorders, 3rd edition
Pure menstrual migraine
– Episodes manifest in a menstruating individual meeting the criteria for migraine without aura
– Occur from two days before to the third day of menstruation
– Present in a minimum of two out of three menstrual cycles
– Absence of occurrence outside the menstrual cycle
– Episodes manifest in a menstruating individual meeting the criteria for migraine without aura
– Occur from two days before to the third day of menstruation
– Present in a minimum of two out of three menstrual cycles
– Possibility of occurrence outside the menstrual cycle
Diagnostic tests
– Blood test
– CT scan
– MRI
– Electroencephalogram [EEG] to rule out seizures.
Management and treatment protocols
General lines of treatment
Menstrual related migraines (MRH) pose a unique challenge in treatment and management. Therapeutic lifestyle measures can play a significant role in controlling migraines, including ensuring proper sleep hygiene, maintaining a healthy diet, sticking to routine meal schedules, regular exercise, and identifying and managing migraine triggers such as stress, alcohol, weather changes, and, most commonly, hormonal fluctuations.
Effective management of menstrual-related headaches begins with pinpointing where the headache aligns within the patient’s menstrual cycle. For those already on oral contraceptive pills (OCPs), adjusting the hormone regimen by reducing oestrogen doses can help prevent MRH by limiting the premenstrual decline in oestrogen, a trigger for MRH.
If hormonal therapy is not preferred, not tolerated, or contraindicated, common abortive therapies include triptans, which target the direct pathophysiologic mechanisms of migraines. Triptans work by blocking trigeminal nerve activation, inhibiting the release of vasoactive peptides, and promoting vasoconstriction.
Nonsteroidal anti-inflammatory drugs (NSAIDs) such as mefenamic acid can also be effective, particularly for treating acute MRH and relieving general dysmenorrhea.
In emergency room settings, intravenous metoclopramide has been shown to be as effective as triptan therapy for acute migraines. However, potential side effects such as akathisia may need to be managed with diphenhydramine, although it does not improve migraine severity.
In severe cases of chronic, intractable migraine headaches, or status migrainosus, dihydroergotamine, an alpha-adrenergic blocker vasoconstrictor and potent serotonin receptor agonist, may be considered. Additionally, medications targeting calcitonin gene-related peptide (CGRP) activity, such as CGRP antagonists, offer novel options for acute migraine treatment in patients with inadequate responses or contraindications to first-line medications.
For those averse to oral or intravenous medications, nerve blocks like the sphenopalatine ganglion block can be considered. Neuromodulation techniques such as transcutaneous electrical nerve stimulation and single-pulse transcranial magnetic stimulation, as well as surgical deactivation of migraine trigger sites, are options reserved for patients with poor responses or contraindications to pharmacological interventions, although data on their efficacy are limited.
The use of opioids in treating MRH is generally discouraged due to potential long-term changes in the central nervous system, including increased descending facilitation from the rostral ventromedial medulla and upregulation of pain afferents, which can lead to medication overuse headaches and exacerbate migraine symptoms.
Simple tips to follow during menstrual cycle
– Apply Ice: Use a cold cloth or ice pack on your head or neck.
– Practice Relaxation: Learn relaxation exercises to reduce stress, a common headache trigger.
– Try Biofeedback: Monitor and manage your body’s stress response with biofeedback techniques.
– Consider Acupuncture: Acupuncture may alleviate headaches and promote relaxation-
– Use of Nonprescription Pain Relievers: Take NSAIDs like naproxen sodium or ibuprofen for quick pain relief.
– Use Triptans: These medications block pain signals and can relieve headaches within two hours.
– Use Anti-nausea Medications: Treat nausea and vomiting with medicines like prochlorperazine or promethazine.
– Gepants: Calcitonin gene-related peptide antagonists are newer migraine treatments.
– Other Prescription Pain Medications: Your healthcare provider may recommend other prescription options like dihydroergotamine.
Care during pregnancy
– Most of the times migraines stop during pregnancy because oestrogen levels increase quickly in early part of pregnancy and stay that increased levels all throughout the pregnancy
– If there is a regular headache, then it is advised to speak to the healthcare worker as some kinds of headaches do have a negative impact on the mother and developing baby.
– Headaches which go off during the pregnancy might show up after delivery because of the sudden drop of oestrogen levels after giving birth to a baby. It might be due to stress, sleep disturbance or dietary changes
– If the headache returns after childbirth and is continuous and not responding to rest and relaxation, then it is advisable to consult the medical professional.
Care of headache, if birth control pills are cause for hormonal headaches
Birth control pills, patches or vaginal rings serve as hormonal contraceptive medications. These can help headaches in a few people but might be worse in others. As these hormone pills help in minimizing the oestrogen drop, the episodes of headaches might be less or severity might be low. Hormonal pills are a good choice if one is not a smoker and doesn’t have migraine with aura. If birth control pills are the reason for the headaches, then a different treatment protocol should be followed which includes –
– Use monthly birth control pill pack with fewer placebos
– Stop placebo days completely for most months with extended-cycle oestrogen-progestin pills.
– Choose birth control pills with lower oestrogen dose to reduce drop in oestrogen during placebo days
– Take NSAIDs and triptans during placebo days
– Use low dose oestrogen pills or oestrogen patch during placebo days
– Adjust birth control patch use to include oestrogen patch on fourth week
– Consider minipill (norethindrone) if unable to take oestrogen-progestin pills
Care during perimenopause and menopause
Hormone-related migraines can worsen during perimenopause due to fluctuating hormone levels. Menopause is reached when periods cease completely.
– Migraines may improve after menopause, but tension headaches can worsen.
– Medications and other therapies can help manage ongoing headaches.
– Hormone replacement therapy (HRT) may be used during perimenopause and menopause.
– HRT can either worsen, improve, or have no effect on headaches.
– Oestrogen skin patches provide a steady supply of oestrogen and may be recommended.
– If HRT worsens headaches, dosage adjustment or a different form of oestrogen may be suggested.
– Smoking while on HRT should be discussed with a healthcare provider.
What are the complications and limitations of drug therapy?
Triptans, while generally safe, have contraindications such as cardiovascular issues and potential interactions with other medications. Avoid in patients with Prinzmetal angina or CAD due to coronary vasospasm risk. Careful screening for hypertension, hypercholesterolemia, and other risk factors is necessary. Chronic use may lead to reduced effectiveness and persistent headaches.
Oral contraceptives (OCPs) should be avoided in older smokers and those with multiple CAD risk factors, hypertension, or history of thromboembolism. Migraines with aura increase the risk of ischemic stroke with OCP use.
NSAIDs are not recommended for patients with peptic ulcer disease or renal issues due to gastrointestinal and renal side effects. Patients at cardiovascular risk may have heightened embolism risk with NSAID use due to reduced prostaglandin I2 production.
Preventive measures
– To prevent severe headaches, consider NSAIDs or triptans.
– For regular menstrual cycles, taking headache medicine before and during your period can be effective.
– If migraines occur frequently, daily medication like beta blockers, antidepressants, or magnesium may be recommended.
– Monthly injections of calcitonin gene-related peptide monoclonal antibody could be an option if other medications fail.
– Your healthcare provider will consider your medical history to prescribe appropriate medication.
– Lifestyle changes such as stress reduction, regular meals, and exercise can also help manage headaches.
– If migraine frequency or intensity escalates, or there’s a shift in your headache pattern.
– If new or altered side effects are manifesting.
– The current medications exhibit decreased efficacy.
– The headache onset is abrupt.
– Enduring an experience like “most severe headache of my life”.
– Following a head injury, you develop a headache.
– Encountering unfamiliar neurological symptoms such as speech impairment, imbalance, vision disturbances, cognitive fog, seizures, or sensations of numbness/tingling.
Prognosis
Menstrual related headaches don’t cause any damage to the brain and they can be managed with simple tips and a few medications.
Ayurveda Understanding of Hormone Headaches / Menstrual Migraine
Hormone Headaches or Menstrual Migraine shall be understood and treated on the lines of Vataja Shirashula / Shiroroga. It shall also be considered as Ardhavabhedaka Shiroroga / Shirashula and treated on the same lines. Ardhavabhedaka headache has been compared to Migraine headache and Hormonal Headache is also a type of Migraine and hence also called by the name ‘Menstrual Migraine’.
Related Reading – ‘Hormone Headaches – Ayurveda Understanding’
