Menstrual Migraine: A Test plus Tips for Primary Care

Question 1: A 25-year-old woman  presents with headaches in association with menses that don't respond to OTC pain relievers and can last up to 72 hours if not treated. What is the most likely diagnosis for her headache? 

Answer: C. Migraine headache. The most likely diagnosis is migraine given the association with menses, duration of the attacks, the cognitive dysfunction, and the lack of efficacy of OTC NSAIDs. 

Question 2: Approximately what percentage of women with migraine have menstrual migraine? 

Answer: D. ~60%. About 60% of women with migraine have menstrual migraine, which is equivalent to >10 million women with menstrual migraine in any given year in the US.

Question 3: Which symptom/s of a headache support the diagnosis of migraine?

Answer: B. Nausea. Epidemiologic studies show that 73% of migraineurs experience nausea with some of their migraine attacks. 

Question 4: A diagnosis of menstrual migraine requires that migraine occurs how often? 

Answer: D. In association with at least 66% of menses. The ICHD states that to make the diagnosis of menstrual migraine, a migraine attack must occur with at least 66% of a woman's menstrual cycle. Also, this migraine must occur within -2 to +3 of a woman's cycle. 

Question 5: True or false? Pure menstrual migraine is more common than menstrual-related migraine. 

Answer: B. False. Menstrual-related migraine is more common than pure menstrual migraine with the latter occurring exclusively with menses. This distinction is important as the treatment approaches are different. 

Question 6: For an otherwise healthy woman aged 25 years who is a non-smoker and whose only Rx is combined ethinyl estradiol/ progestin contraceptive pill, what would be a reasonable first-line treatment option for her migraine attacks?

Answer: B. Sumatriptan 100 mg. Triptans are migraine-specific and typically more effective than OTC or Rx-strength NSAID. 

Question 7: Herbal preparations that show some efficacy for migraine prevention include all of those listed above except which one? 

Answer: D. Vitamin D. Vitamin D has not been shown effective for migraine prevention while efficacy for B₂, butterbur, magnesium, and CoQ10 for prevention of migraine has been demonstrated in clinical trials. The strongest level of evidence is for butterbur, which is now listed as Category A evidence in published guidelines for migraine prevention.⁵

Question 8: Which of the above would not be an additional treatment option for the same healthy 25-year-old woman? 

Answer: D. Short-term prevention with a SSRI (not advised). SSRIs (eg, fluoxetine, sertraline) have been shown to help prevent premenstrual dysphoric disorder (PMDD), but there is no evidence to support their use as a short-term preventive treatment during the luteal phase.