Learn how to diagnose and manage menstrual migraine symptoms with evidence-based strategies for primary care, OB/GYN and neurology providers.

Published: August 22, 2025 | Updated: August 29, 2025

Menstrual migraine affects approximately 60% of women with migraine yet remains significantly underdiagnosed in clinical practice. This hormonal-triggered condition requires coordinated care to improve patient outcomes and quality of life.

“In a primary care setting, especially OB/GYN offices, it’s important to expect migraine,” said Ricardo A. Herrera, M.D., neurologist and headache medicine specialist with Norton Neuroscience Institute. “Research shows that about 1 in 3 patients in a general primary care waiting room has migraine, but in OB settings, that number may be closer to 2 out of 3. Why? Because 85% of people with migraine are women, and OB practices tend to see women in their childbearing years: the exact demographic most affected by hormonal migraine.”

Diagnostic criteria and clinical recognition

Accurate menstrual migraine diagnosis requires adherence to established International Headache Society criteria:

Core diagnostic features:

• Duration: Four to 72 hours (untreated)
• Intensity: Moderate to severe (5 or higher on pain scale of 10)
• Associated symptoms: Nausea, photophobia, phonophobia (one of three)
• Headache characteristics (two or more): Unilateral location, pulsating quality, aggravation by activity

Duration differentiates migraine from tension-type headache. Providers may ask patients: “Can you feel your heartbeat in the headache?” to identify pulsative quality.

Menstrual migraine is a migraine attack occurring exclusively from two days before or two days after the onset of menstruation, triggered by estrogen fluctuations or withdrawal. These episodes demonstrate increased severity, prolonged duration and reduced treatment responsiveness.

Hormonal influences and contraceptive management

Estrogen fluctuation, not absolute levels, triggers menstrual migraine. Hormonal interventions show variable efficacy, requiring individualized approaches.

Clinical management strategies include continuous combined oral contraceptives, extended-cycle formulations or hormonal IUDs (levonorgestrel). Progesterone-only methods are preferred for migraine with aura patients due to reduced thrombotic risk.

Evidence-based treatment strategies

For predictable cycles, perimenstrual prophylaxis offers targeted intervention, such as naratriptan or frovatriptan, initiatedtwo to three days before anticipated menstruation.

Patients with frequent attacks (more than four monthly) require daily preventive therapy. Options include beta-blockers (propranolol, metoprolol), anticonvulsants (topiramate), Botox (for chronic migraine) or calcitonin gene-related peptide (CGRP) monoclonal antibodies.

Magnesium and riboflavin in combination with cognitive behavioral therapy can help prevent or reduce symptoms.

Pregnancy management

Pregnancy alters migraine patterns, with first-trimester exacerbation often followed by improvement. Migraine management requires careful risk-benefit analysis.

Acute treatment

Preferred agents:

• Acetaminophen 1000 milligrams
• Metoclopramide 10 milligrams
• Ondansetron 4 to 8 milligrams

Conditional use:

• Triptans: Sumatriptan preferred based on registry data

Preventive therapy

Safe options:

• Propranolol 80 to 160 milligrams daily
• Magnesium 400 to 600 milligrams daily
• Riboflavin 400 milligrams  daily
• OnabotulinumtoxinA (Botox): Emerging evidence suggests safety

Contraindicated

• CGRP inhibitors: Unknown fetal effects
• NSAIDs: Teratogenic risk (first trimester), oligohydramnios (third trimester)
• Valproate: Teratogenic, developmental delays

Special considerations for migraine with aura

Combined hormonal contraceptives can increase stroke risk in migraine with aura patients.

Risk factors include smoking, thrombophilic disorders, high blood pressure and age 35 and older. Alternative approaches include progestin-only contraceptives, nonhormonal methods and stroke risk counseling.

“We suggest that estrogen-containing medications remain below 20 mcg per day; however, avoiding estrogen entirely and opting for progestin-only formulations can be another option,” said Dr. Herrera.

Clinical implementation framework

Treating menstrual migraine requires systematic clinical approaches combining accurate diagnosis, pattern recognition and evidence-based interventions. Providers must prioritize comprehensive history-taking, individualized treatment plans and coordinated multidisciplinary care between primary care, gynecology and neurology.

Systematic assessment

1. History: Detailed headache diary, menstrual tracking
2. Pattern recognition: Cyclical timing, severity variations
3. Disability assessment: Migraine Disability Assessment (MIDAS) or Headache Impact Test (HIT-6) scores

Treatment algorithm

1. Acute management: Optimize current therapies
2. Cycle tracking: three-month headache/menstrual diary
3. Targeted intervention: Mini-prophylaxis versus continuous prevention
4. Monitoring: Regular follow-up, treatment adjustment

It is important to educate patients about migraine trigger identification and avoidance, medication compliance importance, when to seek emergency care and pregnancy- planning considerations.