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Case Study - Menstrual Migraines
Posted June 2000

Here is a fairly typical case of a woman who gets menstrual migraines and how her doctor helps her manage them.

Initial Visit: Suzy, a thirty-four-year-old social worker and mother of two children, gets severe migraines for four days each month, usually beginning one day before her menstrual period. She has regular periods, every twenty-eight days, and no other health problems. She has tried, with little or no benefit, ibuprofen, Fiorinal, Midrin, Tylenol 3, Vicodin and Excedrin.

Because Suzy usually begins sensing the migraine just prior to the beginning of her period, she is advised to start naproxen, an NSAID, three days before her menstrual period. Naproxen is particularly effective in preventing menstrual migraines. For an abortive medication, the doctor prescribed sumatriptan (Imitrex) tablets because Suzy does not want to give herself injections at this time.

Week 16: Suzy reports that the naproxen helped for the first two months, but then lost its effectiveness. The Imitrex tablets do not help much. Suzy's doctor prescribes flurbiprofen (Ansaid), another NSAID, as a preventive medication, Imitrex injections and a small dose of dexamethasone (Decadron) as an abortive medication.

Week 24: Suzy says the flurbiprofen was not effective and because she gets incapacitating and prolonged (four days) migraine attacks, she is prepared to try hormonal therapy to prevent them. She and her doctor discuss fully the risks and possible side effects, from nausea, hot flashes, and rashes to vaginal discharges, weight gain, and shortness of breath. Suzy receives a prescription for estrogen to take before her periods to prevent the attacks. Her abortive regimen is working in that it shortens her attacks significantly.

Week 32: The estrogen is not effective, so Suzy's doctor prescribes tamoxifen (Nolvadex) to take for one week before menstrual periods.

Week 40: Suzy reports that the tamoxifen is working well and that she feels in good control. When she does get a migraine, the Imitrex injections and dexamethasone usually help.

The future: Other possibilities as preventive approaches include: low-dose (continuous) birth control pills, water pills (diuretics) used prior to the menstrual period, or triptans (Imitrex, Amerge, Maxalt, Zomig, Relpax) used for four or five days. As-needed ergotamines, strong narcotics, injections of Toradol (injected by Suzy at home) or Stadol Nasal Spray are additional possibilities.