Menstrual-Related Headache (Period Headache)

Menstrual-related headaches are a common type of headaches experienced by women, often due to a decrease in estrogen during their menstrual cycle. For successful treatment, these headaches need to be correctly identified in relation to the menstrual cycle or in connection with hormone treatments, typically starting 2 days before menstruation begins up to the third day of the period. Various medications are used to treat and manage menstrual-related headaches, including drugs called Triptans, anti-inflammatory medicines (known as NSAIDs), and different types of hormone therapy.

Menstrual-related headaches, or migraines, often involve a few key factors, particularly a hormone called estrogen. This hormone interacts with the body’s serotonin and glutamate systems, which are part of the central nervous system. This interaction links estrogen directly with headaches. When estrogen levels drop during a specific phase of the menstrual cycle, known as the late secretory phase, the body produces less serotonin. This leads to a rise in two substances – the calcitonin gene-related peptide (CGRP) and substance P – which are known to contribute to migraines. These substances cause dilation of blood vessels in the brain and make the trigeminal nerve, a major pain pathway, more sensitive. They also increase the permeability of the blood-brain barrier, which leads to the release of inflammation-causing substances in areas that are sensitive to pain.

The pain of these headaches can seem more intense around the time of menstruation because the body’s natural painkillers, called endogenous opioids, are less active, thereby worsening the pain.

It’s important to look at a patient’s family history when they come in with a severe headache. Genetic differences in the way certain proteins in the membrane expressed can make some people more prone to migraines. Other factors that might affect the risk include certain medications, such as combined hormonal contraceptives. In particular, people who take higher doses of estrogen are more likely to experience these menstrual-related migraines due to sudden drops in estrogen levels during specific stages of the menstrual cycle.

Migraines are a common health issue, affecting roughly 12% of people. They tend to occur more often in women than in men. Typically, women most frequently experience migraines from their early 30s to early 40s. It’s also common for women to have headaches related to their menstrual cycle, especially during the time leading up to menopause, which is likely because of changing estrogen levels. In fact, almost half of all women have at least one migraine by their early 50s.

Migraines affect about 12% of people and are more common in women than in men.
Women are most likely to have migraines between their early 30s and early 40s.
Menstrual-related headaches are frequent during the time leading up to menopause due to fluctuating estrogen levels.
Up to 41% of women will experience a migraine by their early 50s.

Menstrual-related headaches, often similar to other types of migraines, typically involve a throbbing sensation, usually last for about a day, occur on one side of the head, and can be quite severe. They are commonly associated with feelings of nausea and can make light and sound unbearable, causing the sufferer to seek relief in a dark, quiet room. Such headaches tend to occur during specific periods of the menstrual cycle – roughly between two days before the start of the menstrual period and the third day of bleeding.

Typically, people with these headaches have a normal neurological exam. However, some may experience a condition known as cutaneous allodynia. This is when light touches – such as brushing hair or even wearing contact lenses – can cause pain. This is due to a heightened sensitivity in the body’s pain pathways. Sometimes, patients can find it uncomfortable to rest on the side where they experience this heightened sensitivity.

While it is rare, medical research suggests that these types of migraines could potentially increase the risk of certain conditions, such as Bell palsy (a sudden weakness in facial muscles), sensorineural hearing loss, and issues with the cranial nerves that control eye movements.

Headaches related to a woman’s menstrual cycle are typically diagnosed based on a patient’s symptoms and history rather than imaging tests. That said, sometimes a magnetic resonance imaging (MRI) scan may show changes in the brain’s white matter. These changes are linked to increased blood flow to the brain, a break down of the blood-brain-barrier, and local swelling in the brain, rather than a lack of blood supply to the brain. Usually, during a migraine, there is increased blood flow throughout the brain, and this may last for more than 48 hours especially in the cerebral cortex, thalamus, and basal ganglia.

Imaging tests like an MRI or a computed tomography (CT) scan are only needed if the headache is different in intensity, location, or duration from previous headaches. Migraines cause blood vessels within the brain to widen and trigger the trigeminal nerve, which is sensitive to pain. This results in inflammation in the meninges, the protective layers of the brain. It also makes the blood-brain barrier more permeable, releasing substances that promote inflammation. The decision on which test to use is based on why it is needed, how well it can diagnose the condition, availability of the MRI or CT scan machines, the radiologist’s expertise, and any factors that may prevent the patient from undergoing the test. Both CT angiogram and MR angiogram can be used to image the arteries and veins. For menstrual-related headaches, normal imaging is expected and is sometimes used to rule out other conditions in an emergency situation.

According to the International Classification of Headache Disorders, 3rd edition, there are two categories of menstrual-related migraine. Pure menstrual migraine attacks happen in women who typically get migraines without aura. These attacks happen 2 days before menstruation starts until the third day of menstruation. This pattern must occur in at least 2 out of 3 menstrual cycles and should not occur at other times of the cycle. Menstrually related migraines are also attacks in women who typically get migraines without aura. They occur 2 days before menstruation starts until the third day of menstruation but can also happen at other times of the cycle. This pattern must occur in at least 2 out of 3 menstrual cycles.

Maintaining a balanced lifestyle can help manage migraines. This includes getting enough sleep, eating a balanced diet, sticking to regular meal times, exercising regularly, and controlling triggers such as stress, alcohol, and changes in the weather. Hormonal changes, particularly those related to the menstrual cycle, are often a common trigger for migraines.

Headaches related to the menstrual cycle can be managed by monitoring when they occur in relation to the menstrual cycle. If a woman already uses oral contraceptives, changing her current hormone regimen could prevent the headache. One way to do this is by reducing the estrogen dose to avoid a sharp fall in estrogen levels before menstruation, which can trigger a headache.

For women who prefer not to use hormonal therapy, are struggle with keeping to their treatment, or cannot use it due to health issues, triptans are a common alternative. Triptans directly target migraines by activating certain serotonin receptors that block the pain, preventing activation of the trigeminal nerve, inhibiting the release of certain peptides that affect blood vessels, and promoting vasoconstriction.

Most NSAIDs, commonly known as painkillers, can effectively treat some women. Mefenamic acid, in particular, has been studied in depth for its benefits in treating acute menstrual-related headaches and relieving general menstrual pain.

Administering metoclopramide intravenously can be as effective as triptan therapy when treating severe migraines in an emergency situation. However, potential side effects like restlessness can occur, but can be prevented with antihistamines like diphenhydramine.

Dihydroergotamine, a medication that blocks certain adrenaline receptors and constricts blood vessels, is generally only employed in severe, chronic migraine cases.

New drugs that block CGRP, a molecule that seems to be involved in transmitting pain signals during a migraine, are emerging as alternatives for patients who cannot take first-line medications or those for whom these medications do not work.

Methods that do not involve medication, like nerve blocks, can also be considered. For instance, patients who do not wish to take oral or intravenous medications could be suitable for a sphenopalatine ganglion block. This involves placing an anaesthetic-soaked cotton swab into one nostril of the patient – the same side as the headache – and leaving it in place for at least 10 minutes.

Neuromodulation techniques, which simulate nerves using an electrical or magnetic signal, can also be used in some cases. This treatment is usually reserved for patients who respond poorly or are unable to use medication.

Opioids are generally avoided in treating menstrual-related headaches due to the potential for long-term changes to the nervous system, which can lead to medication overuse headaches. Long-term use of opioids can also increase the body’s sensitivity to pain.

Headaches that are related to menstrual cycles can have various causes, such as stress or cluster headaches. The way to differentiate these from menstrual-related headaches (MRH) is to look at the patient’s symptoms and history. Certain patients may feel pain from small actions like brushing their hair or touch their scalp. This is due to heightened sensitivity in the central pain pathways – often seen in migraine patients. These episodes are usually short, lasting seconds to minutes. However, if these episodes become more intense and frequent, this could signal a condition called trigeminal neuralgia, which requires a different treatment approach.

Additionally, secondary headaches can be caused by several factors: trauma, blood vessel injuries, malignant growth of cells, or infections. These kinds of headaches, which could be from conditions like brain aneurysms, blood clot in the brain, tear in the lining of a blood vessel, inflammation of the brain, or even meningitis, have unique characteristics. These can usually be confirmed or ruled out with certain lab tests, additional brain scans, or by looking at the cerebrospinal fluid (a fluid that surrounds the brain and spinal cord), which is usually collected via a procedure called a lumbar puncture.

Also, MRH rarely comes with an ‘aura’ – a type of sensory disturbance often experienced before a migraine – so it is less likely to be mistaken for a small, temporary blockage in the brain’s blood flow. Understanding an MRH involves looking at the duration, timing, severity of pain, comparing it to previous headaches, performing a neurological exam, and looking at other symptoms during and after the headache.

Women experiencing headaches related to their menstrual cycle typically have a positive outlook. These headaches usually improve with standard medication. However, the effectiveness of this treatment can depend on how regular a woman’s menstrual cycle is. Those with inconsistent menstrual cycles may not respond as well to treatments that target hormones.

Triptans are usually safe to use, but there are certain conditions where they should not be used. For instance, anyone with heart disease should be checked for high blood pressure, high cholesterol, history of smoking, being overweight, diabetes, a family history of coronary artery disease, and menopause before starting treatment. They should not be used by anyone with Prinzmetal angina or coronary artery disease due to the increased risk of coronary vasospasm. Also, it’s important to share your full medication history to avoid any harmful drug interactions. For instance, if you’re taking antidepressants, there’s a higher risk of developing serotonin syndrome. Chronic use of triptans could lead to changes in the brain’s pain processing pathways, which might result in a constant feeling of head pain.

Oral contraceptive pills have specific limitations too. If you’re over 35 and smoke, have 2 or more risk factors for coronary artery disease, have a known heart valve disease, high blood pressure, history of blood clot in the veins, certain genetic disorders like antiphospholipid syndrome or systemic lupus erythematosus, a history of stroke, or breast cancer, or if you have migraines with aura, these pills aren’t recommended. All these conditions increase blood clot risk and can lead to an embolism. There is research indicating that combined hormonal contraceptives are associated with higher risk of stroke in women with migraines with aura.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are not recommended for people with peptic ulcer disease or those with a higher chance to develop gastroduodenal disease, because they block prostaglandin that protects the stomach lining. People at higher risk for heart disease might be limited in using NSAIDs because they reduce certain compounds leading to higher clotting risk. Also, if you have kidney disease, you should avoid NSAIDs as they block substances that support kidney function.

If you often have headaches or if they are very painful, keeping a headache diary for a month might be helpful. In this diary, you could note down how long each headache lasts, how severe it is, and where you feel the pain. You could also note whether or not treatments help to relieve the headache. It may also be useful to keep track of potential triggers like certain foods, alcohol, stress, weather changes, or what point you are in your menstrual cycle. This diary can help you notice patterns, identify what might be causing your migraines, and figure out what helps to soothe them.

Frequently asked questions

Menstrual-related headaches are a common type of headaches experienced by women, often due to a decrease in estrogen during their menstrual cycle.

Up to 41% of women will experience a migraine by their early 50s.

Signs and symptoms of Menstrual-Related Headache (Period Headache) include: - Throbbing sensation in the head - Lasting for about a day - Occurring on one side of the head - Can be quite severe - Associated with feelings of nausea - Light and sound can become unbearable - Sufferer seeks relief in a dark, quiet room - Typically occurring between two days before the start of the menstrual period and the third day of bleeding - Normal neurological exam for most people, but some may experience cutaneous allodynia - Cutaneous allodynia is when light touches cause pain, such as brushing hair or wearing contact lenses - Heightened sensitivity in the body's pain pathways - Uncomfortable to rest on the side where heightened sensitivity is experienced - Rarely, these types of migraines could potentially increase the risk of certain conditions such as Bell palsy, sensorineural hearing loss, and issues with cranial nerves controlling eye movements.

Menstrual-related headaches, or migraines, are caused by a drop in estrogen levels during the late secretory phase of the menstrual cycle. This drop in estrogen leads to a decrease in serotonin production and an increase in substances that contribute to migraines, such as calcitonin gene-related peptide (CGRP) and substance P. These substances cause dilation of blood vessels in the brain, increase sensitivity in the trigeminal nerve (a major pain pathway), and release inflammation-causing substances in areas sensitive to pain. Additionally, the body's natural painkillers, called endogenous opioids, are less active during menstruation, which can worsen the pain.

The doctor needs to rule out the following conditions when diagnosing Menstrual-Related Headache (Period Headache): 1. Headaches related to stress or cluster headaches. 2. Trigeminal neuralgia, if the episodes become more intense and frequent. 3. Secondary headaches caused by trauma, blood vessel injuries, malignant growth of cells, or infections. 4. Conditions like brain aneurysms, blood clot in the brain, tear in the lining of a blood vessel, inflammation of the brain, or meningitis. 5. Small, temporary blockage in the brain's blood flow (aura) that is often experienced before a migraine.

The types of tests that may be needed for Menstrual-Related Headache (Period Headache) include: 1. Magnetic Resonance Imaging (MRI) scan: This test can show changes in the brain's white matter, such as increased blood flow, breakdown of the blood-brain barrier, and local swelling in the brain. 2. Computed Tomography (CT) scan: This imaging test may be necessary if the headache is different in intensity, location, or duration from previous headaches. 3. CT angiogram or MR angiogram: These tests can be used to image the arteries and veins. It is important to note that imaging tests are typically not needed for diagnosing menstrual-related headaches, as the diagnosis is usually based on a patient's symptoms and history. These tests may be ordered to rule out other conditions or if the headache is atypical.

Menstrual-related headaches, also known as period headaches, can be treated in several ways. One approach is to monitor when the headaches occur in relation to the menstrual cycle and adjust hormone regimens, such as reducing estrogen levels, to prevent triggering a headache. Oral contraceptives can be used for this purpose. Triptans are another common alternative for women who prefer not to use hormonal therapy or have difficulty sticking to their treatment. These medications target migraines by blocking pain receptors and promoting vasoconstriction. NSAIDs, particularly mefenamic acid, can effectively treat acute menstrual-related headaches and relieve general menstrual pain. In emergency situations, metoclopramide can be administered intravenously and is as effective as triptan therapy. Other non-medication methods, such as nerve blocks and neuromodulation techniques, can also be considered for patients who do not wish to take oral or intravenous medications or are unable to use medication. Opioids are generally avoided due to the potential for long-term changes to the nervous system and medication overuse headaches.

When treating Menstrual-Related Headache (Period Headache), there can be potential side effects. These include restlessness when administering metoclopramide intravenously, but this can be prevented with antihistamines like diphenhydramine. It's important to note that opioids are generally avoided in treating menstrual-related headaches due to the potential for long-term changes to the nervous system and increased sensitivity to pain. Additionally, chronic use of triptans could lead to changes in the brain's pain processing pathways, which might result in a constant feeling of head pain.

The prognosis for Menstrual-Related Headache (Period Headache) is generally positive. These headaches usually improve with standard medication. However, the effectiveness of treatment can depend on the regularity of a woman's menstrual cycle. Women with inconsistent menstrual cycles may not respond as well to treatments that target hormones.

A gynecologist or a headache specialist.

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