The important cause of migraine for women has finally been found

"Crash", "Send me away", "It's killing me", and "It's too painful, too painful" are the words that migraine sufferers often say when they have an attack.

Migraines affect the quality of life, but when migraines meet menstruation, it's a human tragedy.

You're not alone when it comes to menstrual headaches ...... Even as many as 70% of women with migraines report headache attacks related to menstruation.

Migraines are more "female-friendly"

Migraine is a common primary headache, the kind of headache that is recurrent but never identified as a problem. It typically presents as a unilateral, throbbing moderate to severe headache, accompanied by nausea, vomiting, fear of light and noise, and fear of activity, lasting 4 to 72 hours.

Although both men and women can suffer from migraines, migraines are more common in women, with 3 out of 4 migraineurs being female, and epidemiology shows that 17% of women worldwide suffer from migraines.

Compared to men, migraines in women are more often unilateral, throbbing, and more often associated with nausea, photophobia, and fear of noise, resulting in higher levels of disabling ......

The 2016 Global Burden of Disease Study shows that migraine ranks first among all conditions that may cause disabling conditions in women of childbearing age (15 to 49 years).

Many factors trigger migraines, but many women with migraines have a magical coincidence -

When you get your period, your migraine comes with it, and it can even get worse. It's like having a migraine on top of menstrual cramps.

But this may not be just a coincidence.

Menstruation.

The double whammy of menstrual cramps and migraines

When it comes to menstruation, most women have a bad experience with menstrual cramps, edema, and mood changes ...... but that's only part of the annoyance. What adds to the pain for many women is menstrual migraines.

Research has found that of all the factors that can trigger migraines in women, menstruation may be the most powerful and common one.

We define the period from 2 days before to 3 days after menstruation as the "perimenstrual period" (5 days in total), and migraines that occur during this time are called menstrual migraines.

To rule out chance, the 3rd edition of the International Headache Diagnostic Criteria requires 2 migraine attacks in 3 consecutive menstrual cycles to diagnose menstrual migraine.

If the migraine occurs only during the perimenstrual period and is only associated with menstruation, it is called pure menstrual migraine.

If migraine attacks occur at other times during the menstrual period, it is called menstrual-related migraine.

Why is "menstrual migraine" such a painful problem? The answer still starts with three hormones: estrogen, progesterone, and prostaglandins.

Menstruation is not just simple monthly bleeding, it contains the monthly hormonal cycle changes in a woman's body.

Before bleeding, estrogen and progesterone drop sharply, and prostaglandins are released into the bloodstream from the endometrium during the first 2 days of menstruation.

Migraine attacks on days 1 and 2 of menstrual bleeding may be related to prostaglandins and are usually the most severe at this time.

Originally, the estrogen-based migraine protective factors (e.g., oxytocin, progesterone, etc.) could be in a dynamic balance with the various pro-migraine factors.

However, when menstruation comes, estrogen withdraws, causing the balance to break down and the scale to tip in favor of the pro-migraine factors, resulting in a migraine attack.

Menstrual migraines may persist

until menopause

It is a somewhat harsh truth that menstruation brings us more than simply those few days of inconvenience and menstrual pain.

And the point at which that ends may be after menopause - the prevalence of migraines tends to approach that of men in women before and after their first menstrual period.

After all, the cyclical drop in estrogen each month leads to a cyclical disruption of the dynamic balance of migraine protective and pro-emergent factors in women.

Looking at the entire female life course, migraines haunt us in the following way.

The prevalence of migraine in women increases significantly after the first menstrual period.

During pregnancy, estrogen rises sharply and women with migraine without aura will get significantly better, especially in the middle and late stages of pregnancy; migraine with aura may worsen, and a few new migraines during pregnancy will manifest as aura-type.

Postpartum estrogen will drop sharply, and combined with poor sleep and exertion, migraines will reappear within a short time.

In perimenopause, when menstruation gradually becomes irregular, coupled with menopause-related insomnia, mood swings, and other unfavorable factors, migraine may appear to worsen transiently.

Finally, when menstruation is completely over, migraine will gradually improve, especially menstrual migraine.

How to treat menstrual migraine?

The overall principles of acute treatment are the same as those of acute treatment of regular migraine.

However, because menstrual migraine has its special characteristics, we have compiled several other treatment modalities.

1. Short-course preventive treatment during the perimenstrual period

Suitable for people: those who have regular menstruation and whose migraine is mainly concentrated in the perimenstrual period.

Preference is given to long-acting agents (frovatriptan is preferred and has the most evidence from clinical trials, as domestic drug-free programs are not repeated).

Recommendations based on existing domestic conditions.

Option 1, naproxen (500 mg twice daily) may be initiated after menstrual bleeding or the first perimenstrual headache episode (whichever is earlier) for 5-7 days; this option is more appropriate for women with comorbid dysmenorrhea.

Option 2, is continuous zolmitriptan (2.5 mg each time, 2-3 times daily) on the expected day of migraine onset (usually 2 days before - 3 days after menstruation).

Option 3, which has less evidence but may also be tried because of the low side effects compared to the others, is to start magnesium supplementation on the 15th day of menstruation and continue until the start of the next menstrual period.

Considering that the menstrual cycle can be long or short, it is difficult to determine the exact timing of initiation of treatment, and that there is more or less variation in the options offered by different guidelines and literature, it can be said that there is hardly a one-size-fits-all option.

It is recommended to try short-term prevention regimens of different time points and lengths according to individual seizure patterns and to minimize the number of days of medication while ensuring adequate efficacy.

2. Hormone replacement therapy

In terms of pathogenesis, all the above treatments are remedial measures after the emergence of the migraine fire, but the timing of putting out the fire is slightly different.

The principle of hormone replacement therapy is to minimize the cyclical fluctuations of sex hormones, especially estrogen. Hormone replacement therapy includes oral pills containing estrogen and progestin, contraceptive rings, and contraceptive patches.

Suitable for: people with contraceptive needs, combined with dysmenorrhea, excessive menstruation, endometriosis, etc.

Although it sounds good in principle, the use of hormone replacement therapy for migraine is limited in reality. On the one hand, its high-quality clinical evidence is lacking, mostly from low-quality observational studies, and large-scale clinical trials are still needed to verify the efficacy. On the other hand, neurologists do not use and dare not use contraceptives, and gynecologists do not see headaches ......

Estrogen has a wide range of effects and its side effects limit some of its applications, such as a possible increased risk of stroke and breast cancer. Migraine with aura is also supposed to be a risk factor for cardiovascular diseases such as stroke, so estrogen use is prohibited for migraine with aura. Taking a step back, in terms of pathogenesis, high levels of estrogen increase the risk of aura migraine attacks, and estrogen should not be used to prevent aura migraine.

In addition to migraine with aura, estrogen use is also contraindicated in women with risk factors for cardiovascular disease such as smoking, hypertension, hyperlipidemia, obesity, and hyperglycemia.

If we simply understand the pathogenesis, migraine is the inheritance of a sensitive brain that has a very low threshold for headache attacks.

Most headaches do not occur as a result of a single factor, but rather a combination of multiple factors, with one adverse factor after another superimposed until a migraine attack, is triggered.

Menstruation, as a necessary event for women of reproductive age and a major trigger of menstrual migraine, becomes unspeakable and tremendous torture for women, after all, the various discomforts of menstruation are painful enough for women ...... Starting by understanding the migraine pattern of menstruation and going for migraine management in time, you may be able to improve your quality of life better.