Know your menstrual cycle so you know when you’re likely to get a migraine, and be ready with a migraine action plan—either a preventive drug to prevent a migraine from arising, or an abortive drug to stop it once it’s begun; or,
Use hormones, such as birth control pills, to alter your menstrual cycle. It’s not safe for all women to do this.
Before we discuss these options, let me strongly recommend that you work with your headache specialist to devise your treatment plan, whether it includes prescription drugs, over-the-counter drugs, or something else. Your specialist should know what drugs you are taking and inform you of the benefits and risks of each, and he or she should keep an up-to-date record of your treatment plan. And it’s important to have your ob-gyn involved as well.
Preventive Drugs
For women with regular menstrual cycles, a preventive drug may be helpful. Because we know when your migraines are likely to arise, we can treat them with what I like to call a “preemptive strike” to attack your migraines before they start. There are two kinds of preventive medications to consider: daily or monthly meds. Which is best for you depends on the frequency and severity of your migraines. For more, see Ch. 9.
Daily preventive meds. Daily preventive medications are for migraineurs who get a significant number of severe migraines each month that they can’t necessarily predict. If you get just one or two migraines a month, this is probably not the right choice for you. But if you get three or more each month, and it takes you two or more days to get over each one, it’s an option to consider, and one I often recommend. Daily preventive medications include topiramate, valproic acid, and verapamil.
Periodic preventive meds. Periodic preventive medications are for use before a particular circumstance in which a migraine is likely to occur. For many women, this means your period. Each month, two days before you expect to get a migraine, you take the preventive medication. For example, if you usually get a migraine three days before your period begins, you take a preventive drug two days before that.
Important note: Periodic preventive drugs are useful for any situation when you are certain a migraine will be coming and you want to prevent it, not just for menstrual or menstrual-related headaches. Men can take them, too. One of my patients always gets a migraine when she visits her aunt, who wears excessive perfume and smokes a pack of cigarettes a day, so this patient takes a preventive med two days before she visits—and avoids getting sick.
Abortive Migraine Drugs
Prescription Abortive Drugs. Perhaps your periods are irregular and so you can’t predict with much accuracy when a menstrual-related migraine will appear. In that case, a periodic preventive drug isn’t appropriate, and an “abortive” drug is your best option. An abortive drug is taken at the first sign of an oncoming migraine (which is why you need to know your warning signs: See Ch. 3.)
Abortive migraine drugs include over-the-counter drugs such as ibuprofen, aspirin, or migraine-specific over-the-counter drugs, as well as prescription drugs such as ergot derivatives. For most people, the most effective abortive drugs are triptans. If taken correctly, they often prevent or stop the head pain, nausea, and other effects of migraine. See Ch. 9.
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OTC Drugs Have Side Effects, Too
A note on using over-the-counter drugs: You may incorrectly believe they are less likely to cause side effects than prescription drugs. Not so. Many OTC migraine medications have significant amounts of caffeine, so that when you stop taking them, you may end up with a rebound headache. Over-the-counter drugs have other side effects, too. See Ch. 9.
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Over-the-Counter Medications. For less severe migraines, you may consider taking a type of over-the-counter medications called “nonsteroidal anti-inflammatory” meds (NSAIDs), pain medications that you know as ibuprofen, naproxen, indomethacin, and aspirin; basically, all over-the-counter pain medications except acetaminophen.
While NSAIDs are not powerful enough to be effective for everyone, you may find they are all you need to treat your menstrual migraine. PMS symptoms are thought to result from a chemical surge: The drop in estrogen causes an increase in prostaglandin, and then a cascade of white blood cells that come rushing in, triggering cramps, migraine, and other pain. NSAIDs can derail the white blood cell response, which may be enough to help you with your menstrual migraine. Some NSAIDs are developed specifically to relieve menstrual-related symptoms. For the most effective relief, you should take these drugs starting two days before your period. Talk to your doctor about taking an NSAID preventively before your period begins.
Herbal Treatments
In recent years, herbal treatments have become more popular for treating menstrual symptoms including headache. For comprehensive information on herbal treatments for migraine, which I generally do not recommend, please see Ch. 11.
Tell your headache specialist about any herbal treatments you are using or considering to ensure that you aren’t endangering your health. And if you are pregnant or breastfeeding, you must tell your ob-gyn and your pediatrician of any herbal supplements, vitamins, or drugs you are taking or considering (including herbal teas, as some are dangerous to your fetus), to make sure you don’t injure the baby. Feverfew, an herbal treatment for migraine, is not safe to use while you are pregnant or breastfeeding.
Oral Contraceptives and Migraine
There are many different brands and types of oral contraceptives, and a variety of delivery methods including some that aren’t actually oral, such as the patch, ring, or an injection. In general, these contraceptives work by releasing estrogen and progesterone into your body in levels that prevent ovulation, alter the lining of the uterus to stop a pregnancy from developing, and change the biochemistry of the cervix to block sperm. When taken as directed, these contraceptives are 98 percent effective in preventing pregnancy.
For most women—except for those with specific contraindications, including smokers and those with a history of stroke—oral contraceptives are safe. And for most migraineurs, they are safe, too. However, there is a valid concern about a potential increase in the risk of stroke for migraineurs who use oral contraceptives, especially if they experience aura during migraine. Several studies suggest that the risk of stroke does increase under these circumstances, although the oral contraceptives prescribed today are different from those analyzed in past studies because today’s pills have much less estrogen. Low-estrogen oral contraceptives are associated with only a very slight increase in the risk of stroke, but this risk can jump if you have other risk factors including smoking or high blood pressure. Talk to your doctor to make sure hormones are safe for you.
If you are considering taking oral contraceptives, you should inform your ob-gyn about your migraines, especially if you get migraines with aura. And also tell your headache specialist if you are taking or considering oral contraceptives. If you experience any change in your headache pattern while on oral contraceptives—for example, if they get worse or you have new symptoms—talk to your doctor right away.
A more likely consequence of taking oral contraceptives is that your migraine will change in some fashion. Some women find that their migraines get better, others find they are worse. Some women experience their first migraine when they begin taking oral contraceptives.
If you get severe migraines while on oral contraceptives, stop taking them and talk to your doctor immediately. There is evidence of some chance of increased risk of stroke for migraineurs who use oral contraceptives, especially if you have other risk factors such as high blood pressure or smoking.
If you have a problem with migraines while on the pill, you may find that switching to a different type of pill ends your headaches. The former theory was that the best kind of oral contraceptive was one that mimicked your natural cycle, so the most common kind of pill in days past was the so-called “triphasic pill,” which provided fluctuating amounts of hormones throughout the month. Women who used a triphasic pill often continued to get migra
ines because their hormone levels continued to fluctuate. If you are on a triphasic pill and getting migraines, talk with your doctor about switching to a monophasic pill, which provides a steady amount of hormones throughout the month. This may end the problem. Or, you can choose to take a preventive drug two days before the inactive phase of the pill—the seven days when you’re getting no estrogen at all—or to take an abortive medication to stop a migraine once you feel it coming.
Stopping Your Period
If your menstrual or menstrual-related headaches are really severe, you may want to consider reducing the frequency of your periods. Certain new oral contraceptives can stop your menstrual cycle for up to three months at a time, something called menstrual suppression. There is also a new pill approved in 2007 by the FDA that you take daily and it stops you from menstruating indefinitely for as long as you continue taking it. This may sound like an extreme treatment but may be an effective new way to treat hormonal migraines as well as other painful symptoms related to your period, such as cramps. For some women, these drugs may eliminate hormonal migraines entirely, and so they are worth considering.
Sarah, forty-two, had been suffering from severe menstrual migraines since she was a teenager. Each month around her period, she was laid up in bed for a full week, creating a serious problem for her at work, not to mention how it affected her enjoyment of life. She had tried every kind of treatment but just couldn’t get her migraines under control. When Sarah came to see me, she clearly had had enough. She and I decided that stopping her period might be the solution. I asked her first to check with her gynecologist before we decided to try this.
Here’s how the method worked for her: Each day for eighty-four days, she took one of the new menstrual-suppression drugs, a combination estrogen/progesterone pill. During that time, she didn’t have her period at all. She then stopped taking the pill for seven days and instead took sugar pills (these aren’t necessary, but for many women it’s just easier to remember to take a pill every day). That’s the point at which she got her “period,” which technically wasn’t a period but rather “withdrawal bleeding.” It was a very light amount of blood, and after two to three cycles on this pill, she had no withdrawal bleeding at all during her “off” week. During this “withdrawal week” or “off week,” she did often get a migraine, so she took a nonsteroidal pill, naproxen, every day, which warded off her migraines.
For many women, it is safe to stop periods this way. Our female ancestors didn’t get their periods every month because, for one thing, they were usually pregnant and/or lactating throughout much of their lives. Modern women get around four hundred periods over their lifetime, compared to nineteenth-century women, who got only about fifty. Women today begin menstruating as early as age ten or eleven, whereas a century ago, the average age was sixteen. What’s changed? We’re not sure, but it may be related to chemicals in the environment, the high rates of obesity, or a combination of these factors. While it sounds strange, the truth is that you do not need to get a monthly period. The general medical consensus is that it’s safe to skip several periods in a row. In fact, the fewer periods you have over your lifetime, the better for your health. After being on oral contraceptives for a number of years, your chances of developing ovarian cancer may drop.
You can take these contraceptives in pill form, through a patch that you apply to your skin and change weekly, or through a ring with hormones implanted in it, which you insert into your vagina. One minor potential problem, no matter which delivery form you choose, is that you may develop “breakthrough bleeding” if you decide to skip a period. With breakthrough bleeding, you leak small amounts of blood at unpredictable times. This is not the same as having your period and you will not get a hormonal migraine with it.
Reducing the number of your periods is not the right choice for everyone. Some women are not comfortable with skipping a period, while others can’t tolerate oral contraceptives at all. Others have risk factors—such as smoking, or a family history of stroke—that contraindicate the use of supplemental hormones. But if this method sounds like something you may want to try, talk to your doctor to see if you are a good candidate.
Migraines During Your Life Cycle
As we’ve seen, the changes in hormone levels each month during your menstrual cycle can exert a powerful influence on your migraine illness. And at various phases in your life during which your hormones change significantly, including during pregnancy, postpartum, while you’re breastfeeding, and after menopause, your migraines may change in frequency, severity, and symptoms. Your treatment plan may need to change as well.
Let’s look at migraine during significant milestones in your life.
Planning for Pregnancy
“My migraines were horrible, but when I told the neurologist I was planning to get pregnant, he said there was absolutely nothing he could do to help me. He said there were no drugs safe for me to take, and he never mentioned nondrug therapies like biofeedback. When I pleaded for some relief, he said, ‘Come on, migraines aren’t going to kill you.’ When I think about how condescending he was, I practically get a migraine!”
—Stephanie, 42, freelance editor
In general, you should avoid medications of any sort when you are pregnant, especially during the first trimester. But I also believe that it’s asking a lot of women to endure severe migraines while they are trying to get pregnant, which may take months or years. Some migraine medications are typically safe for women who are trying to get pregnant but should be stopped once you do become pregnant. While some doctors are very cautious and won’t prescribe them for a woman trying to conceive, I respect my patients and their attention to their own health and that of their unborn child. My approach is to inform my patients fully about the risks of migraine drugs for a fetus, to discuss their options, and to work together to create a plan that helps them deal with migraine without hurting the baby.
One of my patients, who had been taking a triptan to relieve severe migraines, came to see me when she was trying to get pregnant. I gave her a prescription for a prenatal vitamin, and then we talked about the best options for her migraines. I told her the only time she could use a triptan was when she was certain she wasn’t pregnant: If she wasn’t sure if she was pregnant, she should avoid using a triptan. I also gave her a prescription for a safe painkiller in case she got a severe migraine and needed pain relief but wasn’t sure if she was pregnant. I advised her to try to avoid using it unless it was absolutely necessary. (This is a decision you should make in close consultation with your doctor.) I also cautioned her to come to my office immediately if she noticed anything new and unusual about her headaches (which is always something you should do with your doctor, but even more so if you are or might be pregnant).
Always discuss your pregnancy plans with your headache specialist. While trying to conceive, avoid taking aspirin, which can interfere with the implantation of the egg.
As a migraineur planning to become pregnant, you want to use this time to get really healthy. Don’t smoke, don’t drink, and exercise at least five times a week for at least half an hour. Start to wean yourself off caffeine but don’t go cold turkey, which can trigger a migraine. Ask your headache specialist or primary care physician for a year’s worth of prenatal vitamins before you start trying to get pregnant, because you want to start to build up your supply of folic acid, which is essential for the fetal nervous system. You want to do everything you can to be healthy so you can have a healthy baby.
Pregnancy
“I never had a migraine until I got pregnant. I was twenty-seven, and instead of getting morning sickness or any of those typical early-pregnancy symptoms, I started having really, really bad headaches. I spent the early part of my pregnancy lying in a dark room.”
—Ciara, 36, computer programmer
“When I’m pregnant, I don’t get migraines. No, no, not at all. It’s lovely.”
—Flannery, 37, veterinary technician
For mo
st migraineurs, pregnancy is a time of bliss. More than half find their headaches decrease by 50 percent in their first trimester, and it only gets better after that. At least 75 percent find that their migraines significantly improve, if not disappear altogether, in the second and third trimesters. For them, the final six months of pregnancy are a kind of migraine-free nirvana.
Unfortunately, this isn’t the case for all women. Fifteen percent report that their headaches get worse during the first trimester, and some find no relief later in the pregnancy. There’s really no way to predict how your body will react. It wouldn’t hurt to ask your mother about her migraines during pregnancy, but that’s no guarantee you’ll react the same way, especially as some women find their migraine experience varies from one pregnancy to the next. In any event, most women find that their migraine status returns to its normal state once the baby is born (unless they are breastfeeding, as we’ll discuss below.)
Beth was one of my patients who had completely different experiences with migraines during each of her pregnancies. With her first pregnancy, her headaches were almost constant during the first trimester. It’s hard to explain why this was so but perhaps it was because her hormone fluctuations were more severe. With her second pregnancy, she had almost no migraines during the first trimester.
The Migraine Brain Page 13