The drop in oestrogen just prior to menstruation is a known trigger for migraine and in women migraine is more frequent, more severe and harder to treat just before and during menstruation.

In some women migraine only occurs (pure menstrual migraine) or predominantly occurs (menstrually-related migraine) from two days before the start of bleeding until three days after. In these women perimenstrual strategies may be used instead of, or in addition to, standard, continuous prophylaxis. The menstrual cycle has to be regular for treatment to be effective.

Recommendation Consider frovatriptan (2.5 mg twice daily) as a prophylactic treatment in women with perimenstrual migraine from 2 days before until 3 days after bleeding starts.

Recommendation Consider zolmitriptan (2.5 mg three times daily) or naratriptan (2.5 mg twice daily)  as alternatives to frovatriptan as prophylactic treatment for 2 days before until 3 days after bleeding starts.

Good practice point tickWomen with menstrual-related migraine who are using triptans at other times of the month should be advised that additional perimenstrual prophylaxis increases the risk of developing medication-overuse headache.