Part of the Access Doctor migraine treatment guide. Conditions overview: migraine & headache UK.
Menstrual Migraine: Why It Happens, Treatments & HRT Options UK
A clinically reviewed guide to menstrual migraine — the oestrogen withdrawal mechanism, acute treatment, perimenstrual prophylaxis, hormonal prevention, the contraceptive pill safety issue, and HRT in perimenopause.
▶ Menstrual migraine at a glance
Around 60% of women with migraine have attacks triggered by menstruation — specifically the fall in oestrogen in the days before a period. Menstrual attacks are often more severe and longer-lasting than non-menstrual attacks. NSAIDs (particularly naproxen) are especially effective. Perimenstrual prophylaxis can prevent attacks without daily medication. Important: combined pill is UKMEC 4 in migraine with aura. GPhC pharmacy #9011198.
60%
Of women with migraine have menstrual attacks
Day−2 to +3
Perimenstrual window when attacks most common
Longer
Menstrual attacks are often more severe and last longer
UKMEC 4
Combined pill classification for migraine with aura
Why Menstrual Migraine Happens
Menstrual migraine is driven by the fall in oestrogen that occurs in the late luteal phase (days before menstruation). This oestrogen withdrawal lowers the migraine threshold in susceptible women.
Prostaglandins released during menstruation also play a role — this is why NSAIDs (which inhibit prostaglandin synthesis) are particularly effective for menstrual migraine.
Pure menstrual migraine (attacks ONLY around menstruation, not at other times) occurs in about 10% of women with migraine. Menstrually-related migraine (attacks around menstruation AND at other times) is much more common, affecting around 50-60% of women with migraine.
Types of Menstrual Migraine
| Type | When attacks occur | Prevalence |
|---|---|---|
| Pure menstrual migraine | Exclusively days −2 to +3 of menstruation; no attacks at other times | ~10% of women with migraine |
| Menstrually-related migraine | Around menstruation AND at other times of the month | ~50–60% of women with migraine |
Acute Treatment
Standard acute migraine treatment applies. Specific considerations for menstrual migraine:
- NSAIDs (naproxen 500mg) — particularly effective due to the prostaglandin mechanism. Take at the first sign; continue as needed. Naproxen for migraine guide →
- Triptans — effective and appropriate. First-line for moderate to severe attacks. Triptans guide →
- Triptans + naproxen combined — superior to either alone, particularly for prolonged menstrual attacks
Perimenstrual Prophylaxis
For women with predictable, regular periods, short-course prevention taken around the expected attack window (day −2 to +3) can significantly reduce or prevent menstrual attacks without the need for daily preventive medication.
| Option | Regimen | Notes |
|---|---|---|
| Naproxen 500mg twice daily | Starting 2–3 days before expected period, continuing for 5–7 days | Anti-prostaglandin mechanism; particularly suited to menstrual migraine |
| Frovatriptan or naratriptan | Started 2 days before expected period for 6 days | Longer-acting triptans; used preventively in this context; via specialist/GP |
Hormonal Prevention
For women with menstrually-related migraine without aura, oestrogen supplementation to smooth the perimenstrual hormone drop is an option:
- Transdermal oestrogen patches (100 microgram) applied 3 days before expected period, continued for 7 days — delays the oestrogen withdrawal trigger
- Continuous combined OCP (no pill-free interval) — eliminates the withdrawal drop; only appropriate in migraine without aura
Migraine with aura: Oestrogen supplementation and combined hormonal contraceptives are contraindicated in migraine with aura due to stroke risk (UKMEC 4 for COC). Progestogen-only methods (mini-pill, implant, IUS) are safe — UKMEC 1. See: migraine and the pill →
HRT and Migraine in Perimenopause
Perimenopause is associated with worsening migraine frequency due to fluctuating oestrogen. Transdermal HRT (patches or gel) provides stable oestrogen levels and often improves migraine. Oral HRT can cause oestrogen fluctuations and may worsen attacks.
Migraine with aura and HRT: transdermal oestrogen + progestogen HRT has a more favourable safety profile than oral HRT in migraine with aura — though UKMEC guidance should be followed and the balance of risks discussed with your GP.
Discuss Migraine Treatment Online
Our GPhC-registered prescribers can assess menstrual migraine, acute treatment, and perimenstrual prophylaxis options. GPhC pharmacy #9011198.
Start Consultation →For HRT options in perimenopause and menopause: hormone replacement therapy at Access Doctor →
Frequently Asked Questions
Why do migraines get worse around my period?
Oestrogen falls sharply in the 2 days before menstruation. This oestrogen withdrawal lowers the migraine threshold in susceptible women. Prostaglandins released during menstruation also contribute, which is why NSAIDs like naproxen are particularly effective.
What is the best treatment for menstrual migraine?
Naproxen 500mg and triptans (sumatriptan or rizatriptan) are both effective for acute menstrual migraine. The combination is superior to either alone. For predictable cycles, perimenstrual prophylaxis with naproxen twice daily or a longer-acting triptan starting 2 days before the period can prevent attacks.
Can the pill help with menstrual migraine?
Only if you have migraine without aura. A combined oral contraceptive taken continuously (no pill-free interval) eliminates the monthly oestrogen drop and can prevent menstrual attacks. The combined pill is absolutely contraindicated (UKMEC 4) in migraine with aura due to stroke risk.
Does menopause cure menstrual migraine?
After menopause, many women find their migraine frequency decreases as hormones stabilise. However, perimenopause (the transition) often causes worsening migraine due to erratic oestrogen fluctuations. Transdermal HRT can stabilise hormones and improve migraine in this period.
Is menstrual migraine covered under the NHS?
Acute treatments and preventive medicines for menstrual migraine are available on NHS prescription. Online prescriptions are available through Access Doctor following a clinical consultation.
References
- NICE. Headaches in over 12s: diagnosis and management. CG150.
- MacGregor EA. Menstrual migraine. Neurol Clin. 2009.
- UKMEC. UK medical eligibility criteria for contraceptive use. 2016 (updated 2019).
- NHS. Migraine. nhs.uk/conditions/migraine
Medical disclaimer: This article is for informational purposes only. Prescription migraine treatments require a clinical consultation. Always consult a qualified healthcare professional. In a medical emergency, call 999.