Menstrual migraine

The International Headache Society, whose classification doctors use to name headaches, describes two kinds. In pure menstrual migraine, attacks come only from two days before a period starts to its third day, in at least two of every three cycles, and at no other time. In menstrually related migraine, attacks come in that window and at other times too. Pure menstrual migraine is the rarer kind, a small minority. Period attacks are mostly migraine without aura, the society says.

A 2021 review in The Lancet Neurology, by Vetvik and MacGregor, puts menstrual migraine at about 20 to 25% of women with migraine in the general population.

In Pakistan, a nationwide door-to-door survey published in 2017 found that 26.9% of women had had migraine in the past year, and that migraine was most common between the ages of 40 and 49. We found little research on the link with periods here.

Cleveland Clinic, the US hospital, lists symptoms for it that match the NHS migraine page: pain often on one side of the head, feeling sick, and being very sensitive to light and sound.

The difference is the timing, and the weight. The NHS says menstrual migraines "are often longer and more severe than migraine attacks at other times."

The International Headache Society says there is some evidence that, at least in some women, the attacks come from the fall in estrogen just before a period, though other changes at that point may play a part.

Perimenopause can turn the volume up. Women's Health Concern, the British Menopause Society's patient arm, says migraine often gets worse in the years before menopause, with attacks coming more often, lasting longer and more likely to start a few days before or during a period. The main reason, it says, is estrogen rising and falling, and periods that come more often mean more migraine. The British Menopause Society and the European Menopause and Andropause Society (EMAS) also link it to fluctuating estrogen, and EMAS adds that hormones are not the only cause.

After menopause, it often eases. Women's Health Concern says many women find migraine improves as periods stop, though not at once, and migraine with aura is less likely to improve. A 2025 Norwegian study of 4,825 women with migraine, by Bugge and others, found that 46.3% still had migraine after menopause. So often, not always.

• NICE's headache guideline, CG150, asks doctors to suspect menstrual-related migraine when attacks come mostly around the start of a period in at least two of three cycles, and to diagnose it with a headache diary kept for at least two cycles.
• The Migraine Trust, the UK migraine charity, says there is no test for it.
• The International Headache Society notes that many women over-report a link between their attacks and their periods. Written down, the dates show the pattern whichever way it falls. See trigger tracking.

For the attack itself, the British Association for the Study of Headache (BASH), the UK group for headache specialists, says a period attack is treated like any other migraine attack.

For predictable attacks the usual treatment does not control, NICE CG150 asks doctors to consider a triptan, a migraine medicine, on the days an attack is expected. NICE notes this is off-label. BASH lists the same short-term prevention.

With aura, the answer on the combined pill, patch and ring changes. UKMEC, the UK contraception criteria, rates them category 4: "an unacceptable health risk". NICE asks doctors not to routinely offer them for contraception. The NHS says the pill may not be suitable. Women's Health Concern says they are not recommended.

In perimenopause there is another option, and it is not HRT. The British Menopause Society and Women's Health Concern call it hormone cycle control: hormonal contraception used to quieten the ovaries and steady hormone levels, even if you do not need contraception. Without aura, the British Menopause Society names combined contraception. With aura, it names a progestogen-only pill that stops ovulation, with estrogen through the skin if needed for hot flushes, and calls that use off licence. On a lower evidence grade, the International Menopause Society says combined pills may help women without aura by stopping ovulation, but should be avoided by women with other risks to their blood vessels.

HRT is a separate question. Women's Health Concern says HRT started too early in perimenopause can make migraine worse. Aura does not rule HRT out, it says, and with aura it is best to start with estrogen through the skin at the lowest dose that controls hot flushes. The International Menopause Society adds a caution: with aura, estrogen HRT as tablets may carry some added stroke risk. More on this in headaches and migraines.

The NHS says to see a GP if "you regularly get migraine before or during your period." Take your diary.

On HRT, if aura gets worse or appears for the first time, Women's Health Concern says to ask whoever prescribes it. For urgent and emergency signs with any headache, see headaches and migraines.

Periods are hard to talk about in many homes, so a migraine that comes with one gets called tiredness, or part of being a woman. Naming it, with dates beside it, gives you and your doctor something to work with.