Menstrual migraine is a form of simple migraine that occurs due to fluctuations in the level of estradiol in the menstrual cycle. It is clinically manifested by migraine attacks without aura that occur during the menstrual period. Diagnostics includes anamnesis collection, neurological status study, gynecological examination, hormonal status assessment, if necessary, rheoencephalography, cerebral MRI is performed. Relief of paroxysms is carried out with the use of triptans, anti-inflammatory, antiemetic drugs. In preventive treatment, triptans, estrogen preparations are used.
General information
The term “menstrual migraine” refers to migraine attacks that occur in women during the premenstrual period and during menstruation. Pathology is a type of migraine without aura. It is known that 60% of women suffering from migraine report an increased frequency of headache during menstruation. The prevalence of purely menstrual migraine, not accompanied by paroxysms of cephalgia in other periods, varies between 7-14% of all cases in women. It peaks among women of 40 years of age and decreases significantly in menopause.
Causes
The connection of migraine with hormonal background becomes obvious if you study the statistics. The incidence of migraine attacks in both sexes is the same in childhood and old age, in the reproductive period, the incidence of women is 3 times higher than in men. The conducted studies have demonstrated the dependence of the course of migraine on the level of sex hormones, primarily estradiol. A sharp decrease in the latter at the end of the menstrual cycle is the main trigger of the headache that occurs.
Stressful situations, physical overstrain, the use of chocolate, alcohol, citrus fruits during premenstrual days can provoke a painful paroxysm. Factors predisposing to the occurrence of menstrual migraine are considered to be:
- a reduced threshold of pain sensitivity;
- elevated levels of estrogen and progesterone;
- taking hormonal medications, including contraceptives;
- gynecological diseases;
- positive family history.
Pathogenesis
The mechanisms of menstrual migraine are still being studied. The leading pathogenetic theory is currently recognized as the theory of estrogen deficiency. Estrogen receptors are present in almost all cerebral structures, a greater number of them are concentrated in the hypothalamus. By acting on receptors, estradiol regulates the work of neurotransmitter systems, including reducing the activity of nociceptive neurons.
Estrogens are able to modulate the conduct of pain impulses at various levels: at the level of the trigeminal nerve and nucleus, thalamus, conducting tracts, cortical structures. They also affect the synthesis of serotonin, which is involved in the neuron-vascular mechanisms of the development of migraine paroxysm. The sharp drop in the level of estradiol that occurs before menstruation negatively affects the functioning of the above systems, leads to the appearance of cephalgia.
The theory of deficiency is confirmed in clinical studies. So, the introduction of estradiol prevents the occurrence of menstrual migraine paroxysm, and its cancellation leads to the resumption of symptoms. However, hormonal fluctuations also occur in healthy women. Probably, there are genetic features predisposing to the development of migraines against the background of a decrease in estrogen levels.
Classification
The disease was not reflected in the list of nosologies in the International Classification of Headaches, but its diagnostic criteria were defined and set out in the appendix. Compared to headaches that occur in other phases of the cycle, menstrual migraines are more severe in most women and can be longer and more resistant to treatment.
Modern neurology distinguishes 2 types of menstrual migraine. Both forms occur in at least two out of three menstrual cycles, only the time interval of the appearance of a migraine attack differs. According to this criterion , the following types of migraines are distinguished:
- Truly menstrual — cephalgia occurs only in the last 2 days preceding menstruation, lasts until the third day of the cycle. It is about 10% of cases.
- Menstrual-associated — along with the premenstrual period, cephalgia appears on other days of the menstrual cycle.
Symptoms
In typical cases, the disease starts during or within a few years after puberty. In half of the patients, it is combined with premenstrual syndrome. The symptoms of a menstrual migraine attack are identical to the manifestations of other forms of simple migraine. A distinctive feature is the occurrence at a certain period of the menstrual cycle.
Paroxysm begins without previous manifestations with intense dull or pulsating cephalgia affecting half of the head. Photophobia, hypersensitivity to odors, phonophobia are characteristic. There is a lack of appetite, nausea, vomiting without relief, diarrhea. Patients note weakness, dizziness, depressive mood. The duration of the attack varies within 1-3 days.
It is believed that the menstrual form is characterized by the severity of paroxysms. Patients who have other premenstrual attacks, along with others, note a high intensity of cephalgia, pronounced weakness, anorexia, repeated vomiting during a premenstrual attack. In almost all cases, during pregnancy, there is a significant improvement or complete disappearance of cephalgic attacks. Taking oral contraceptives negatively affects the course of the disease, leads to a heavier attack.
Complications
The pronounced severity and long duration of menstrual migraine attacks negatively affects the quality of life of patients, their professional activities. In the absence of adequate treatment, patients anxiously expect every menstruation. The most severe complication is migraine status, in which, due to repeated vomiting and inability to eat, dehydration occurs, electrolyte disorders develop that require urgent medical attention.
Diagnostics
Diagnostic measures are carried out by a neurologist together with a gynecologist-endocrinologist. It is mandatory to collect a family history, interview the patient regarding the frequency of migraine attacks, their connection with the menstrual cycle. The list of necessary examinations includes:
- Neurological examination. The neurological status in the intercalary period corresponds to the norm, which allows us to exclude organic pathology of the nervous system. If changes are detected, rheoencephalography and MRI of the brain are recommended.
- Gynecological examination. It is necessary to identify / exclude the pathology of the reproductive system, assess the condition in the presence of a current gynecological disease. Concomitant gynecological diseases are diagnosed in 75% of patients.
- The study of the level of sex hormones. Allows you to assess the hormonal background, identify its disorders for their subsequent correction.
Differential diagnosis
The disease must be distinguished from premenstrual syndrome. Both diseases occur with the onset of seizures before the onset of the menstrual phase, accompanied by cephalgia, weakness. However, premenstrual syndrome is characterized by emotional lability, dysphoria, hunger, muscle pain, arthralgia, which is not observed in menstrual migraines.
On the basis of clinical features, differential diagnosis with other forms of migraine is also carried out. For the first time, menstrual migraine is differentiated from organic cerebral pathology manifesting hemicrania. Exclusion of intracranial neoplasms, vascular malformations, brain cysts is carried out according to the results of MRI.
Treatment
The most effective therapy includes relief of migraine attacks and prevention of their occurrence. In the presence of gynecological pathology, hormonal imbalance, the patient is simultaneously treated by a gynecologist. The main medications recommended for treatment include:
- Nonsteroidal anti-inflammatory drugs (NSAIDs). Due to analgesic and anti-inflammatory action, the severity of pain syndrome during the attack is significantly reduced. It is possible to prescribe NSAIDs together with triptans.
- Triptans. Being agonists of serotonin receptors, they are able to inhibit the main pathogenetic mechanisms of the disease. They are recommended for preventive therapy and during the seizure period. When taken in the first hours of hemicrania, complete relief of the attack is achieved in 40% of cases.
- Antiemetic drugs. They are necessary for repeated vomiting. Cupping the latter allows you to avoid dehydration, loss of electrolytes.
- Estradiol preparations. They are used in the preventive treatment of true menstrual migraine. According to research, estrogen therapy reduces the frequency of paroxysms by 3 times. With the regularity of the cycle, it is possible to prescribe estradiol 2 days before the start of menstruation with a duration of 7 days. The ineffectiveness of the use of estradiol, as a rule, is due to the erroneous diagnosis of the form of migraine, the appointment of an inadequate dose of the drug.
Prognosis and prevention
Menstrual migraine has a favorable prognosis. The frequency and intensity of her paroxysms decreases, and then completely disappears in postmenopause. Despite some resistance to therapy, adequately selected complex treatment in most cases can significantly improve the quality of life of the patient. Prevention of the occurrence of the disease includes timely detection and treatment of gynecological diseases, correction of hormonal disorders, exclusion of the effects of provoking triggers: fatigue, stress, eating disorders.
