Menstrual Migraine Management: Stages and Stats

During the perimenopausal health session, Antoinette Maassen van de Brink presented on migraines in the transition period, she explained the role hormones have to play in migraine occurrence and potential treatment options in the perimenopausal phase where attacks are felt the most.

Currently migraines remain extremely difficult to define, as there is currently no known fixed biomarker, definition usually comes down to the experience of the patient. It is estimated that migraines impact 15% of the population and can be extremely disabling, with the condition ranked the 3rd most disabling in women by the World Health Organisation.  There is no single known cause of migraines, but it is suspected that 40% of cases are related to genes, it is also thought a number of attacks are related to hormones and stress is also often listed as a cause by patients (although this is not backed up by RCT data).

Although migraines occur in both men and women, they are up to 3 times more prevalent in women.  MacGregor et al (2006) have shown that the incidence of migraines can be dependent on the menstrual cycle. Most migraines occur during the beginning of the menstrual cycles which studies suggest is a result of reduction in estradiol which can trigger a migraine attack.  Data shows that menstrual-related migraines are often migraines without aura (this means they are more severe and difficult to treat). Literature highlights that the highest migraine burden is experienced during the perimenopause phase, with women no longer suffering from migraines post-menopause in most cases. 

So how can we help patients manage migraines during this phase? Treatment options include; acutely acting antimigraine drugs, prophylactics, oral combined contraceptives, hormone replacement therapy and the use of a GnRH agonist. When choosing which option to progress with, focus should be placed on cardiovascular safety. Literature has shown that when a woman is experiencing migraines, she is at increased risk of white matter hyperintensities, stroke and cardiovascular disease. Antoinette believes that the increased risk is due to a female specific vascular dysfunction which results in ischemia ultimately leading to migraines and/or CVD.

Baring these risks in mind, work is being done to look at alternative migraine management options. Currently antibodies that can block the CGRP receptor (which will prevent binding of CGRP and induction of vasodilation) are being tested in phase III clinical trials, with the belief this mode of action may be effective at preventing migraines and hot flushes!

For now, we know that migraines are a highly disabling disease prevalent in women which results in increased risk for long term cardiovascular complications. It is thought that the prevalence and severity of migraines is closely linked to hormonal fluctuations, hence they are experienced most during perimenopause.  We are still looking to establish best practices for treatment during this phase as more data is needed but any prescription of MHT should be done cautiously with evaluation of potential cardiovascular risk in the interim.

Do you have any suggestions about the best treatment for migraines in the perimenopause phase? If so please share with us in the comment section below.