It’s that time of the month … for a migraine

It's “that” time of the month … and your head is throbbing! Chances are that this is a menstrual migraine caused by temporary hormone fluctuations. “Today” contributor Dr. Judith Reichman explains why these headaches happen – and how they can be prevented and treated.

Why do menstrual migraines occur?
Headaches are not equal-gender occurrences. Women are two to three times more likely than men to suffer from migraines; indeed, nearly one-quarter of all women experience them. And when they get them, they are likely to occur just before or during their menstrual cycle.

A drop in estrogen is the trigger. From puberty until menopause, our hormones rise and fall with each period, with estrogen levels rising a few days after the period starts and remaining high through ovulation and the next two weeks. In the absence of a pregnancy, the estrogen level drops, a process that begins one to two days before the actual onset of the period. It is these hormone changes that set up complicated brain reactions in women susceptible to migraines. These include:

• A change in the brain enzyme monoamine oxidase (MAO).
• A decrease in the neurotransmitter, serotonin.
• A decrease in the level of certain endorphins, the brain's natural painkillers.
• Activation of fibers that runs through the trigeminal nerve. (A major nerve that supplies sensation to the front half of the head).
• A sterile inflammation. Brain proteins are released from the irritated nerve fibers causing small vessels in and around the brain to swell, and fluid from these vessels to flow out into the surrounding tissue.  

Menstrual migraines typically begin one to two days before a period, when estrogen levels begin to decrease, and they can last through the first few days of the period, when these levels rise.

And there is one more factor in our headache story -- prostaglandins, which are produced during menstrual bleeding and cause the muscle of the uterus to contract and blood vessels that supply the lining of the uterus to constrict.

Women with severe menstrual cramps may unfortunately produce excess amounts of prostaglandin -- and this substance can also constrict their brain blood vessels and increase the sensitivity of pain receptors in their brain so that they unfairly suffer from headaches in addition to their cramps. (These same prostaglandins can also cause diarrhea, nausea, flushing and concentration problems.)

The symptoms of a migraine
A "typical" menstrual migraine consists of the following segments:

The Prodrome (12 to 24 hours before the migraine begins)
Symptoms consist of:

• Fatigue
• A sense of elation or depression
• Hunger
• Discomfort from light or sound
• A sense of super-sensitivity

The Aura (experienced by about 20 percent of women)
About one in five women will then go through what is called an aura. They see spots or flashes of light for five to 20 minutes before the headache hits. At the same time, they may experience numbness or tingling on one side of the body or even have problems thinking. (Some women get the aura without a subsequent headache.)

The headache phase
The pain is intense, throbbing and often isolated to one side of the head. It's usually accompanied by nausea and even vomiting, and lasts from four to 72 hours.

What makes a woman prone to menstrual migraines?  Does she have a hormonal imbalance?
No. There is no difference in absolute estrogen levels between women who have migraines and women who don't. It's the fluctuation in estrogen that acts as a trigger in susceptible women. Part of this may be genetic – if a family member suffers migraines, your chance of having them is increased four-fold.

Other causes of hormonal migraines.
Aside from our menstrual cycles, there are other hormonal events that can cause migraines.

• Estrogen levels can vary tremendously during peri-menopause (the years before women stop menstruating) and some women develop their worst migraines at this time.
• If a woman ingests hormones, either by means of birth control pills or hormone replacement therapy, when she stops -- as she does on her week off with the pill or on certain types of hormonal replacement therapy -- she may develop a migraine. This type of headache also can occur post-partum, when the high levels of pregnancy hormones plummet after the birth of the baby and the expulsion of the placenta.

Therapy for menstrual migraines
Therapies include hormone control, prostaglandin control, pain control and medications that block the inflammatory-like response in the brain:

Hormone control
This is used to counteract the falling estrogen levels associated with migraines. For some women, continuous dosing of a birth control pill is effective. The pill can also be used during the peri-menopause to prevent the hormonal fluctuations that characterize this phase of our reproductive lives. There is controversy about the 25 percent of women whose menstrual migraines are accompanied by aura. These women may have an increased tendency for stroke and the pill may not be appropriate.

Women who don't want to take birth control pills can augment their "estrogen-low" phase by applying an estrogen patch (such as Climara or Vivelle) two days before the expected migraine -- and keep it on for a week. A dose of 0.5 milligrams or more is needed to augment the estrogen and have an effect on migraines.

Lowering prostaglandin production
Non-steroidal, anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil) and naproxen (Aleve) help accomplish this. They also have the advantage of diminishing brain inflammatory response. They should be started one week before your expected period. Try two to three tablets of ibuprofen two or three times a day or two naproxen tablets twice a day. If these don't work, ask your doctor for prescription-strength NSAIDs, which may be slightly more effective.

Other over-the-counter pain medication
If you didn't succeed in prevention and your head begins to hurt, you can try acetaminophen (Tylenol) or aspirin (with or without caffeine). This may help relieve a mild to moderate headache. (When the bottle says "migraine" on its label -- for example Excedrin Migraine -- it usually contains caffeine).

Prescription migraine medications: Triptans
These activate specific serotonin receptors that cause brain blood vessels to constrict and also decrease irritation of the nerves associated with migraines. There are five triptans currently available by prescription. (One of the most common is Imitrex.) It can be given as a shot, pill or nasal spray, and should not be repeated more than two to three times over 24 hours.

Other prescription medications
Beta blockers and calcium channel blockers (commonly used for heart disease and hypertension) as well as tricyclic antidepressants are often prescribed by neurologists for chronic migraines. A recent study showed that the anti-epileptic drug topiramate also reduced the occurrence of migraines.

Other factors to consider
Migraines, menstrual and otherwise, are also governed to a certain extent by lifestyle choices. To help reduce the chances of these painful headaches, women should also make sure they get regular sleep (not too much or too little), as well as regular meals and exercise. They should also avoid peaks of stress and stay away from dietary triggers. These vary from person to person, but can include excess caffeine, naturally occurring amines (e.g. in chocolate, cheese, wine, some fruits), glutamates (e.g. in tomatoes, mushrooms), MSG and preservatives in meats (such as nitrates and nitrites).

Dr. Judith Reichman, a regular “Today” show contributor, has practiced obstetrics and gynecology for more than 20 years. Her latest book, "Slow Your Clock Down: The Complete Guide to a Healthy, Younger You," is published this month by William Morrow, a division of HarperCollins.

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