1. 39-year-old woman with ‘monthly’ headaches Presented by: Anne MacGregor Barts Sexual Health Centre, St. Bartholomew’s Hospital, London, UK CLINICAL CASE

2. IDENTIFICATION 39-year-old woman with ‘monthly’ headaches The woman seeks help for disabling headaches associated with menstruation

3. CASE PRESENTATION (I) KG is 39-year-old accountant who presents with ‘sick’ headaches Attack frequency –Attack regularly with menstruation lasts three to four days –One to two additional attacks per month lasting one day

4. CASE PRESENTATION (II) Description of attacks –Nasal congestion on waking, which develops into one-sided headache –Headache associated with nausea, light and sound sensitivity Periods regular 5/27-29 days –Menstrual headaches disabling –No other menstrual problems

5. CASE PRESENTATION (III) Treatment –Paracetamol 1 g: effective for non-menstrual headaches not effective for menstrual headaches

6. PAST CLINICAL HISTORY (I) Headaches –Since teens –More frequent over last 10 years –Link with menstruation last 4 years –History of headaches in the pill-free week of combined oral contraceptives

7. PAST CLINICAL HISTORY (II) Asthmatic, treated with inhalers Avoids aspirin and NSAIDs Otherwise healthy Systems review normal

8. FAMILY HISTORY Parents –Mother well – past history of monthly headaches –Father being treated for high blood pressure Siblings –Two brothers both well with no medical complaints

9. PHYSICAL EXAMINATION On examination she looks in good health Physical examination and neurological assessments were unremarkable BP 125/85 mmHg BMI 23.2 kg/m 2

10. DIAGNOSTIC PROCEDURES None indicated –No atypical features in the history –Physical and neurological examinations normal http://tools.aan.com/professionals/practice/pdfs/gl0088.pdf

11. DIAGNOSIS (I) Is it migraine? –KG has had episodic headaches associated with photophobia, nausea, and disability –She is free of symptoms between attacks –Normal physical and neurological examination This suggests a diagnosis of migraine without aura Cephalalgia 2013;33: 629-808.

12. DIAGNOSIS (II) Is it menstrual migraine? –KG describes regular attacks of migraine with her menstrual period and additional attacks at other times of the month This suggests a diagnosis of menstrually- related migraine without aura (Fig. 1) –Diary cards can confirm the diagnosis

13. Figure 1: ICHD III: MENSTRUALLY- RELATED MIGRAINE A. Attacks, in a menstruating woman, fulfilling criteria for Migraine without aura and criterion B below B. Documented and prospectively recorded evidence over at least three consecutive cycles has confirmed that attacks occur on day 1 ± 2 (i.e. days -2 to +3) of menstruation in at least two out of three menstrual cycles, and additionally at other times of the cycle Notes: 1. For the purposes of ICHD-3 beta, menstruation is considered to be endometrial bleeding resulting from either the normal menstrual cycle or from the withdrawal of exogenous progestogens, as in the use of combined oral contraceptives or cyclical hormone replacement therapy. 2. The first day of menstruation is day 1 and the preceding day is day -1; there is no day 0 Cephalalgia 2013;33: 629-808.

14. DIAGNOSIS (III) Diary shows (Fig. 2) –Migraine starting on day -2 of menstruation; duration 4 days –1 additional attack non-menstrual attack; duration 1 day

15. Figure 2: THE HEADACHE DIARY OF THE PATIENT

16. TREATMENT (I) What is her current treatment and is she taking it optimally? –Diary shows menstrual attack did not respond to paracetamol –She delayed treatment for several hours after the headache has started

17. TREATMENT (II) Are there any relevant non-hormonal triggers?

18. TREATMENT (III) Would she benefit from daily prophylaxis? –Depends on attack frequency and response to acute treatment

19. TREATMENT (IV) Treatment management –NSAIDs contraindicated because of asthma –Recommend frovatriptan for treatment of long- duration menstrual attacks –Diary records for three months –Consider non-hormonal triggers

20. FOLLOW-UP Review diary cards to confirm diagnosis of menstrually-related migraine (Fig. 3) Review efficacy of acute treatment and consider need for prophylaxis (Fig. 4)

21. Figure 3: ASSOCIATION BETWEEN MIGRAINE AND MENSTRUATION

22. Figure 4: ACUTE TREATMENT WITH FROVATRIPTAN

23. TREATMENT EVALUATION Diary shows that menstrual attacks respond to frovatriptan and that she treats symptoms as soon as headache starts and repeats for relapse

24. CLINICAL EVALUATION She has reduced the frequency of non- menstrual migraine by avoiding lack of sleep and missed meals Daily prophylaxis is not indicated given her frequency of attacks and response to acute treatment

25. REMARKS (I) Late 30s/40s is the typical age for menstrual migraine to present Diary cards are essential to confirm the diagnosis and assess the effects of treatment Hormonal tests are not indicated Sarchielli P, et al. J Headache Pain 2012;13 Suppl 2:S31-70; MacGregor EA, et al. Neurology 2006;67:2154-2158; MacGregor EA, et al. Neurology 2006;67:2159–2163.

26. REMARKS (II) Long-duration attacks, such as menstrual migraine, need treatments with a longer duration of action, such as frovatriptan Early treatment improves efficacy and reduces pain and functional disability Sarchielli P, et al. J Headache Pain 2012;13(Suppl2):S31-70; Evers S, et al. Eur J Neurol 2009;16:968-981; Bendtsen L, et al. Danish Headache Society, 2nd Edition, 2012. J Headache Pain 13 2012; Suppl1:S1-29; Geraud G, et al. Headache 2003;43:376-388; Cady R, et al. Curr Med Res Opin 2004;20:1465-72.