Menstrual Migraines and Period Control

Not all headaches are created equal: migraine headaches affect more than twice as many women as men. Interestingly, in 60-70% of women, the headaches are related to the menstrual cycle. Period-related headaches that occur from one week to 3 days before the start of your period are called premenstrual migraines. The ones that occur from 3 days before the start of your period to 2 days afterward are called true menstrual migraines.

Menstrual headaches are a classic example of a problem thought to be caused by cyclic hormone changes. Researchers suspect falling and/or low estrogen levels trigger these types of headaches. Either the estrogen made by your body or the synthetic estrogen found in birth control can be the culprit. This means menstruating women, as well as women who use a hormonal birth control method like the Pill on the regular 3 weeks on/1 week off are prone to period-related headaches. Why?

During the menstrual cycle, your body's hormones (both the local ones like estrogen and progesterone, and the control ones like FSH and LH) go up and down. For example, at the end of your period, your estrogen levels start going up, hit a peak about midcycle, and then decline sharply right before the start of your next period. Similarly, when you're taking the Pill, your fake period is triggered by withdrawing the synthetic hormones for one week. In particular, the level of synthetic estrogen goes down suddenly (it takes the body about 24 hours to clear the Pill hormones out of the body), before your own body has a chance to rev up to produce enough estrogen to replace it.



In either case--a dip in natural or synthetic estrogen levels--the result can be a menstrual headache. Can period control help with menstrual migraines? Let's look at some studies.

1. One study measured the timing, frequency, and severity of hormone-related symptoms, including period-related headaches, in 262 Pill users. (The breakdown was 193 current users, and 69 new users). Specifically, the aim was to compare the pattern of headaches during the active-pill (the three weeks with hormone-containing pills) and the placebo pill (the one week hormone-free) interval.

Current users had more headaches during the placebo week than during the three active-pill weeks (70% vs. 53%). Similar headache patterns were seen in new users after the first cycle of use.

CONCLUSION: Headaches were significantly worse during the placebo week interval than during the three active-pill weeks. In other words, although using the Pill on the regular 3 weeks on/1 week off regimen helps with period-related headaches, women on this regimen still experience more headaches during the 1 week off.

2. Another study looked at 50 Pill users who were experiencing period-related problems, like menstrual migraines, during the placebo week. Migraine was the second most frequently occurring problem cited by the women (the most frequent was dysmenorrhea, or a painful period)--78% for dysmenorrhea and 76% for migraine. Also, migraine was most often ranked as the most severe problem (48%). To control their period-related problems, the women were given the option to use an extended, menstrual management regimen.

Women chose a 12-week (84 days on/7 days off) regimen, a 9-week (63 days on/7 days off) regimen, or a 6-week (42 days on/7 days off) regimen. All the women who used an extended regimen reported a delay in onset and a decrease in the severity of period-related problems. Interestingly, one woman reported many days of breakthrough spotting but continued to use the extended Pill regimen because of the relief she experienced from the migraines she used to have during the placebo interval.

CONCLUSION: Using an extended, menstrual management regimen (delaying the fake period by extending the number of consecutive days of active, hormone-containing pills) is well tolerated and efficacious. In other words, using an extended regimen, and shifting the frequency of the fake period from monthly to once every 12 weeks (or 9, or 6 weeks) reduces the placebo-related headaches experienced by women who use the Pill.

3. Finally, a study measured the acceptance and use of extending the number of active-pill days beyond three weeks and/or shortening the placebo interval. All 292 Pill users reported experiencing problems, like headaches, pelvic pain, etc., during the placebo week. The women who chose to use the extended regimen typically used a regimen of 12 weeks on/6 days off. The most common reason given for choosing the extended regimen was headache (35%), followed by dysmenorrhea (21%), heavy periods, or hypermenorrhea (19%), and premenstrual symptoms (13%). Other reasons were: convenience and endometriosis.

In terms of symptom improvement, 86% of the women on the extended regimen reported that their symptoms improved (compared to 41% of women on the regular 21/7 regimen). In terms of quality of life improvement, 94% of the women on the extended regimen reported quality of life improvements (compared to 43% of women on the regular 21/7 regimen).

CONCLUSION: The majority of patients with hormone withdrawal symptoms on OCs [Oral Contraceptives] will initiate a regimen of extending active pills, often with a shortened hormone-free interval to reduce frequency and severity of associated symptoms. In other words, the majority of Pill users who experience symptoms during the placebo week prefer to use an extended, menstrual management regimen to reduce the frequency of the fake period (from monthly to once every 12 weeks), and to lessen the severity of the placebo week symptoms.

Bottom line: For women who experience menstrual migraines and are considering period control, a good first step is using the Pill on the regular 3 weeks on/1 week off regimen. This accomplishes the following:

the period is suppressed for the entire month (actually, it's suppressed for the entire time you use the Pill--months, years)

the body hormones no longer fluctuate

the Pill hormones only fluctuate one week per month

a monthly fake period pattern is established

If the regular 3 weeks on/1 week off regimen doesn't help, the next step is using an extended Pill regimen. This can be a 6-week (42 days on/7 days off), a 9-week (63 days on/7 days off), a 12-week (84 days on/7 days off) regimen, or any other regimen that fits your unique needs. This accomplishes the following:

the period is suppressed for the entire month (again, it's suppressed for the entire time you use the Pill)

the body hormones no longer fluctuate

the Pill* hormones only fluctuate once every 6, 9, 12, etc. weeks

a shift in the fake period pattern, from monthly to once every 6, 9, 12, etc. weeks

Other menstrual migraine treatments include: non-steroidal anti-inflammatory agents (NSAIDs like ibuprofen), 5-HT-1 agonists (sumatriptan), daily prophylactics (beta blockers, calcium channel antagonists, tricyclics), and other hormonal regimens (danazol).

Menstrual migraines are common and they can be very disruptive. Although we don't yet fully understand what causes these headaches, treatments are available. So, if you experience period-related headaches, there's no need to suffer in silence. Ask for treatment, and expect relief.

*monophasic Pill brands