catamenial migraine

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NICE state with respect to Menstrual (catamenial) related migraine (1):

  • suspect menstrual-related migraine in women and girls whose migraine occurs predominantly between 2 days before and 3 days after the start of menstruation in at least 2 out of 3 consecutive menstrual cycles
  • diagnose menstrual-related migraine using a headache diary for at least 2 menstrual cycles
  • for women and girls with predictable menstrual-related migraine that does not respond adequately to standard acute treatment, consider treatment with frovatriptan (2.5 mg twice a day) or zolmitriptan (2.5 mg twice or three times a day) on the days migraine is expected.

Notes (2):

    • prophylaxis for menstrual migraine should be tried for a minimum of three cycles before it is judged ineffective
    • consider using peri-menstrual prophylaxis with an NSAID:
      • NSAID is commenced at the onset of menstruation and continue until the last day of bleeding
      • suitable choices are mefenamic acid or naproxen
    • some state that oestrogen supplements may also be considered:
      • transdermal oestradiol patches 100 microgram may be started 3 days before the onset of menses and continued for 7 days
      • if this is effective but poorly tolerated, a 50 microgram patch can be considered
      • estradiol gel 1.5 mg is an alternative
      • note that provided that the woman is menstruating regularly, additional progestogen for endometrial protection is not required

If a woman is taking the combined oral contraceptive pill:

  • if migraine without aura occurs during the pill-free interval in a cycle of combined oral contraceptives (COCs) consider:
    • alternative contraception methods if the COC is now contraindicated
    • can often be resolved by changing to a more oestrogen-dominant pill
    • as for menstrual migraine, oestrogen supplements can be used during the seven-day pill-free interval
    • taking the pill continuously for 9 weeks rather than 3 ("tricycling"), followed by the usual 7-day pill-free interval, results in 5 rather than 13 withdrawal bleeds per year and is an alternative approach
  • if migraine with aura occurs, the COC must be stopped, and other methods of contraception used
    • do not routinely offer combined hormonal contraceptives for contraception to women and girls who have migraine with aura (1)


  1. NICE (November 2015). Headaches - Diagnosis and management of headaches in young people and adults
  2. British Association for the Study of Headache (BASH) guidelines, 2004.

Last edited 05/2019 and last reviewed 11/2020