Menstrual migraine

Many women with migraine notice that their attacks come around their period. When migraine attacks start between 2 days before a period and the third day of bleeding, headache specialists call it menstrual migraine. Studies suggest that about 1 in 5 women with migraine has this pattern. The main trigger is thought to be the drop in estrogen just before a period. This article explains why it happens, how to confirm it, what to ask your doctor about treatment, and a safety point about birth control if you have aura.

Why do periods trigger migraine?

Estrogen, a female hormone, rises and falls over the menstrual cycle. Just before a period starts, it drops quickly. The leading explanation, called estrogen withdrawal, is that this fall sets off attacks. In a study that measured hormones every day for three cycles, women had more migraine attacks while estrogen was falling and fewer while it was rising.

Prostaglandins, substances made in the uterus that also play a role in period cramps, are thought to be involved too.

Two kinds of menstrual migraine

Doctors call the first day of bleeding day 1 and the day before it day −1. There is no day 0. The window for menstrual migraine runs from day −2 through day 3. The International Classification of Headache Disorders (ICHD-3) describes two patterns:

For both, attacks need to happen in this window in at least 2 out of 3 cycles. The difference between the two matters, because hormone-based prevention is more likely to work for pure menstrual migraine. Most menstrual attacks come without aura.

Why these attacks can be harder to treat

Attacks around a period often last longer and respond less well to treatment than attacks at other times. In a study from Italian headache centers, 13.5% of attacks during the period were pain-free 2 hours after treatment, compared with 32.9% of attacks at other times. Attacks just before and during the period also caused more trouble at work.

Medicine days can add up, too. If you take pain relievers for cramps as well as for headaches, the total climbs. Taking headache medicine too often, month after month (for some medicines, on 10 or more days a month), can lead to medication overuse headache, where the medicine itself causes more headaches.

How to confirm the pattern with a diary

There is no blood test or scan for menstrual migraine. Doctors go by your history, and memory isn't always reliable. Many women think their attacks are tied to their period more often than a diary shows. Because the definition looks at 2 out of 3 cycles, a diary that covers at least 3 cycles gives you and your doctor a clear picture.

• Mark the first day of each period. That's day 1.
• Log every headache day, how bad it was, and how long it lasted.
• Log every medicine you take, including pain relievers for cramps.

After 3 cycles, you and your doctor can see whether attacks cluster in the window, whether they also come at other times, and how often you take medicine. For more tips, see how to keep a headache diary.

In Zutsu Note, you can log your headaches and medicines in a few taps and see your monthly counts on a chart. You can also show a 30-day summary at your appointment on your phone, or print it or save it as a PDF if you use Zutsu Note in a web browser.

Treatment options to discuss with your doctor

There are three main approaches: treating attacks when they start, short-term prevention around your period, and regular prevention. Which one fits depends on how regular your periods are, whether you also get attacks at other times, whether you have aura, and your other health conditions. Make these choices with your doctor.

1. Medicines for attacks

Medicine tends to work best when you take it early. Options include anti-inflammatory pain relievers (NSAIDs) and prescription migraine medicines called triptans, which are sometimes used together. If nausea makes pills hard to keep down, some medicines come as nasal sprays or shots. Learn more about types of migraine medicines.

2. Short-term prevention around your period

If your periods are regular, your doctor may suggest taking a medicine on a set schedule for several days around the start of your period. This is sometimes called mini-prevention. These plans have been studied, but they are not FDA-approved uses. The right medicine and timing differ from person to person, so don't start one on your own. If you also get frequent attacks at other times, the extra medicine days need careful planning to avoid medication overuse.

3. Regular prevention

If you also get attacks at other times of the month, daily preventive treatment can lower the number of attacks overall. Some preventive medicines can harm a developing baby, so tell your doctor if you are pregnant, planning a pregnancy, or could become pregnant.

4. Hormonal approaches

Some doctors use hormones to smooth out the drop in estrogen, for example by using birth control continuously to skip the hormone-free days, or by adding estrogen around the period. Some people who take the pill get headaches on the hormone-free days, and a doctor may be able to change the schedule. Hormones aren't right for everyone. Estrogen can reduce attacks in some people, make them worse in others, or have no effect. These approaches are generally avoided in people who have migraine with aura or other stroke risk factors, and many doctors try other treatments first. Talk them over with the doctor who treats your headaches and with your gynecologist (OB-GYN).

Birth control if you have migraine with aura

Aura is a set of symptoms that usually comes before the headache, each lasting 5 to 60 minutes. The most common kind is visual, such as a zigzag line or a blind spot that slowly spreads. Some people feel tingling or numbness spreading on one side of the body.

For people who have migraine with aura, the CDC's 2024 U.S. Medical Eligibility Criteria for Contraceptive Use advise against birth control that contains estrogen. This includes combined pills (pills with both estrogen and progestin), the patch, and the ring. The guidance places them in category 4, which means “an unacceptable health risk.” The reason is stroke. Migraine with aura and estrogen-containing birth control are each linked to a higher risk of ischemic stroke, the kind caused by a blocked blood vessel. There are other kinds of birth control without estrogen, so talk to your doctor about other options.

For migraine without aura, including menstrual migraine, the same guidance places these methods in category 2: the benefits generally outweigh the risks. That rating assumes no other stroke risk factors, such as older age, high blood pressure, or smoking.

• Tell any doctor who prescribes birth control that you have migraine, and whether you have ever had aura.
• If you notice aura for the first time, or your headaches change after you start birth control, contact the doctor who prescribed it right away.

Perimenopause and pregnancy

Perimenopause is the time before periods stop for good. Hormone levels change in less predictable ways, and migraine can get worse for a while. In a large US survey, women with migraine were more likely to have headaches on 10 or more days a month during perimenopause than before it. After menopause, many women find that their attacks become less frequent.

During pregnancy, many women with migraine without aura get better, especially later in pregnancy. In one study, migraine improved in 83% of women during the second trimester, but it came back within a month after birth in more than half. Migraine with aura is less likely to improve. Ask your doctor about your medicines before you try to get pregnant, or as early in pregnancy as you can.

During pregnancy and in the year after giving birth, get medical care right away for a headache that won't go away or keeps getting worse, or a headache with vision changes. These can be signs of a serious problem.

When to see a doctor

• Attacks around your period make you miss school or work, or keep you in bed.
• You also get migraine at other times of the month, several times a month.
• You take pain medicine for headaches or cramps on 10 or more days a month.
• You have migraine and use, or want to start, hormonal birth control, especially if you have ever had aura.
• Get emergency care right away for a sudden, severe headache, a headache unlike your usual ones, or a headache with weakness or numbness in an arm or leg, or trouble speaking. Call 911 or go to the nearest emergency room.

Menstrual migraine can be treated, so bring your diary to your appointment. To find a headache specialist, see how to find a headache specialist, or try the American Migraine Foundation's doctor finder.

Studies and guidelines we used

• Headache Classification Committee of the International Headache Society. The International Classification of Headache Disorders, 3rd edition (ICHD-3). Cephalalgia. 2018;38:1-211.
• MacGregor EA, et al. Incidence of migraine relative to menstrual cycle phases of rising and falling estrogen. Neurology. 2006;67:2154-2158.
• Vetvik KG, MacGregor EA. Menstrual migraine: a distinct disorder needing greater recognition. Lancet Neurology. 2021;20:304-315.
• Granella F, et al. Characteristics of menstrual and nonmenstrual attacks in women with menstrually related migraine referred to headache centres. Cephalalgia. 2004;24:707-716.
• Nguyen AT, et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2024. MMWR Recommendations and Reports. 2024;73(4):1-126.
• Martin VT, et al. Perimenopause and menopause are associated with high frequency headache in women with migraine: results of the American Migraine Prevalence and Prevention Study. Headache. 2016;56:292-305.
• Sances G, et al. Course of migraine during pregnancy and postpartum: a prospective study. Cephalalgia. 2003;23:197-205.
• American Migraine Foundation. Menstrual migraine treatment and prevention (2021); Hormonal and menstrual migraine (2022); Migraine and menopause (2022); Experts answer FAQ about migraine and women's health (2022).
• Centers for Disease Control and Prevention. Urgent maternal warning signs (Hear Her campaign).