Migraine and menstruation: a pilot study
EA MacGregor, H Chia, RC Vohrah, M Wilkinson
CEPHALALGIA MacGregor EA, Chia H, Vohrah RC, Wilkinson M. Migraine and menstruation: a pilot study. Cephalalgia 1990;10:305-10. Oslo. ISSN 0333-1024 Objective: To define the term "menstrual" migraine and to determine the prevalence of "menstrual" migraine in women attending the City of London Migraine Clinic. Design: Women attending the clinic were asked to keep a record of their migraine attacks and menstrual periods for at least 3 complete menstrual cycles. Results: Fifty-five women completed the study. "Menstrual" migraine was defined as "migraine attacks which occur regularly on or between days -2 to +3 of the menstrual cycle and at no other time". Using this criterion, 4 (7.2%) of the women in our population had "menstrual" migraine. All 4 women had migraine without aura. A further 19 (34.5%) had an increased number of attacks at the time of menstruation in addition to attacks at other times of the cycle. Eighteen (32.7%) had attacks occurring throughout the cycle but with no increase in number at the time of menstruation. Fourteen (25.5%) had no attacks within the defined period during the 3 cycles studied. Discussion: A small percentage of women have attacks only occurring at the time of menstruation, which can he defined as true "menstrual" migraine. This group is most likely to respond to hormonal treatment. The group of 34.5% who have an increased number of attacks at the time of menstruation in addition to attacks at other times of the month could be defined as having "menstrually related" migraine and might well respond to hormonal therapy. The 32.7% who have attacks throughout the menstrual cycle without an increase at menstruation are unlikely to respond to hormonal therapy. The 25.5% who do not have attacks related to menstruation almost certainly will not respond to hormonal therapy. • EA MacGregor, H Chia, RC Vohrah, M Wilkinson, The City of London Migraine Clinic, 22 Charterhouse Square, London ECIM 6DX; Correspondence to Dr MacGregor. "Menstrual" migraine has been recognized since the time of Hippocrates (1). It was referred to by Fordyce in 1758 (2). Since that time many papers have suggested that migraine in women is related to fluctuation in the levels of hormones relating to the menstrual cycle (3-6). The main arguments in favour of hormones as an important influence on migraine are: 1. Migraine is equally common in both sexes (or even more common in boys (7)) up until puberty. After this time it is three times more common in women (8, 9). 2. Many women with migraine report worsening of their headaches around the time of menstruation (10-12). 3. The oral contraceptive pill may precipitate a first attack of migraine or it may worsen or improve the frequency and severity of existing attacks (13-19). 4. Oestrogen injections (7), implants (20), and percutaneous oestrogens (21, 22) have been shown to be beneficial. 5. Many women with migraine have fewer attacks during pregnancy (23-25). 6. The condition may be exacerbated in the post-partum period (26). 7. Some women have fewer attacks or cease to have attacks after the menopause (27). Most of the studies performed have been carried out by means of questionnaires sent out to women asking them if their attacks of migraine were related to menstruation (28, 29). In previous studies the prevalence of "menstrual" migraine ranges from 8% (30) to up to 70% (31). This is largely due to the fact that the definition of "menstrual" migraine is different for each study. Some definitions that have been used include: 1. An attack of common migraine (migraine without aura) occurring exclusively just before or during menstruation (not earlier than two days before menstruation and no later than the last day of the menses) (22).
2. Migraine attacks occurring predominantly during or within 2 days before menstruation (14%) (29). 3. A common migraine (migraine without aura) which occurs during the week before or the week of menstruation; the woman being headache-free for the remainder of the cycle (30). 4. Any migraine headache which occurs 3 days prior to the menstrual flow, during the time of the menstrual flow, or 3 days following (31). At the City of London Migraine Clinic we treat approximately 600 women with headache each year and it was decided to undertake a pilot study to assess the prevalence of migraine associated with menstruation in our population and provide a more specific definition of "menstrual" migraine. Patients and methods
Women attending the City of London Migraine Clinic during a six-month period who suffered from migraine with aura and/ or migraine without aura, as defined by the criteria laid down by the International Headache Society, were asked to keep a record of their migraine attacks and menstruation for at least 3 complete menstrual cycles. This was because the normal follow-up appointment is usually 3 months after the first consultation and most women attend this second assessment. Women were asked to keep the charts as a routine part of their treatment programme. Records kept by women who took the oral contraceptive pill, or who were breastfeeding, were excluded from the data analysis. The data were then analysed by recording the headaches that preceded and followed day 1 (i.e. the first day of the bleeding) of each menstrual cycle. Migraine occurring at the time of ovulation would thus be expected at day -14 for all women even if they did not have a regular 28-day cycle due to the relative constancy of the luteal phase. The pattern of migraine attacks for all three cycles was summed up on separate graphs for each woman. In this way those women having headaches associated with each phase of the menstrual cycle could be easily identified. The results were also summed up as a total of all three cycles for all 55 women. Results
Fifty-five women aged between 17 and 50 years (mean 35.8 ± SD 9.0 years) completed the study with completed records of migraine attacks over 3 menstrual cycles. Eleven women had migraine with aura (20%) and 44 had migraine without aura (80%). Fig. 1 shows the summed attacks of all headaches recorded by the 55 women over 3 complete menstrual cycles. As can be seen, there was a marked increase in migraine attacks recorded around the first day of menstruation (i.e. the start of the bleeding). There was no increase in attacks recorded at the time of ovulation. Attacks recorded at each end of the diagram are due to the variability in the length of the menstrual cycle. Six of the women (10.9%) had migraine attacks occurring only at the time of menstruation and at no other time. Of these, 4 (7.2%) had attacks in all 3 cycles recorded which occurred only between days -2 to +3 of the cycle (i.e. 2 days before menstruation to 3 days after) as in Fig. 2. This graph shows the summed attacks of these 4 patients over the 3 cycles. The other 2 patients had migraine attacks occurring also on day -4 and day +4. Only one woman had attacks of migraine within the -2 to +3 period and at the expected time of ovulation (day -14). The attacks associated with menstruation occurred in all 3 cycles, but the attack at ovulation was only recorded in one cycle. All of the above 7 women had migraine without aura. The majority of women also had attacks of migraine with aura or migraine without aura which occurred at other times of the month. Fig. 3 shows the number of headaches recorded over the 3 cycles when the 4 women with "menstrual" migraine were excluded from the results. It still shows an increase in the hum her of migraine attacks recorded at the time of menstruation. When the indi-
vidual graphs for each woman were studied, it was found that 37 women (67.3%) had attacks during all stages of the menstrual cycle over the 3 cycles studied. Of these, 19 (34.5% of total) had an increased number of attacks within the period defined for "menstrual" migraine and 18 (32.7%) had attacks throughout the cycle but with no increase in number during the defined period. Fourteen women (25.5%) had no attacks within the defined period during the 3 cycles. Discussion
"Menstrual" migraine has been the subject of much debate and many hypotheses about the cause have been formed over the years. As has been shown, the effect of menstruation seems to be most apparent between the days -2 to +3 of the menstrual cycle. There were 2 patients who had purely menstrually associated migraine but with attacks occurring just outside this range. However, it was felt that a cut-off point must be made. From the graph of the total number of headaches occurring over the 3 cycles (Fig. 1), the -2 to +3 period showed the greatest increase in headaches. For this reason it was felt that "menstrual" migraine could be defined as: "Migraine attacks which occur on or between days -2 to +3 of the menstrual cycle and at no other time". Using this definition the prevalence of "menstrual" migraine in our patient population was found to be 7.2% when 3 menstrual cycles were recorded consecutively. This compares to 14.1% found in the study by Epstein et al. (29) when the replies to a questionnaire completed adequately by 92 women still menstruating were analysed and checked by interview. These women claimed a regular relationship of their attacks of migraine to the menstrual cycle, but this was not checked with prospective records. The, original questionnaire was sent to all women over the age of 14 who had attended the Oxford Migraine Clinic over a 3-year period. so the replies were from a self-selected group. Digre and Damasio (30) found 8% of women with migraine have "menstrual" migraine using their definition of "a common migraine that occurs during the week before or the week of menstruation. the women being headache free for the remainder of the cycle". However, they also apply the term "menstrual" migraine to patients who have migraine headaches during the menstrual flow and ovulation.
Migraine attacks associated with ovulation Were not included in our definition as there did not appear to be any women in our series in whom there was a clear association between attacks of migraine and ovulation. Obviously attacks associated with ovulation would not be apparent in anovulatory cycles. Our study number may have been too small and the period of study too short to identify such a group. For the majority of women, menstruation seemed to be a further trigger factor, i.e. most women had migraine attacks occurring at any time of the month, but were still more prone to attacks around the time of menstruation. These attacks should be defined as "menstrually related" rather than as true "menstrual" migraine. Migraine attacks are triggered by several factors and menstruation must act as an additional trigger at that time. This may or may not be a specifically hormonal effect due to a direct action of the hormones or secondary to changes in the hypothalamic-pituitary axis. The effects on other biochemical pathways or even the effect of other trigger factors (dietary, sensory, stress, etc.) may also play a role. It would seem that there are only a few women for whom menstruation seems to be the sole trigger of their attacks of migraine. In summary our study identified 4 groups of women: 1. Those with "menstrual" migraine (7.2%). 2. Those with "menstrually related" migraine (34.5%). 3. Those whose attacks occur throughout the menstrual cycle but with no increase at the time of menstruation (32.7%). 4. Those whose attacks do not occur at the time of menstruation (25.5%). It was felt that further studies are required to identify the specific groups and to analyse any further differences between the groups in the light of previous studies. For example, patients identified as having "menstrual" migraine need to be studied for a much longer period of time to assess whether or not the temporal relationship of attacks to menstruation continues. Also the finding that all 4 women with "menstrual" migraine had migraine without aura needs to be corroborated with larger study numbers. The effect of other trigger factors needs to be studied-a greater link with menstruation may be found by removing as many triggers as possible (e.g. excluding dietary triggers, eating regular meals, reducing caffeine intake, etc.) or it may provide some improvement in attacks for the "menstrual" migraine group A larger series is needed to enable a firm statement to be made about the duration of increased susceptibility. This susceptibility could then be correlated with known hormonal changes and the effect of ovulation, which may have been masked in such a small group as mentioned above. The identification of the 4 distinct groups may well have an implication for the treatment of migraine in women. For example, it is most likely that hormonal treatment will be effective for the group with "menstrual" migraine and may also help the group with "menstrually related" migraine. It is unlikely that hormonal treatment will help those whose attacks are not related to menstruation. Further controlled studies will need to be undertaken to support this hypothesis. In a study such as this it is difficult to overcome the problems of a self-selected study group as only a small number of women were motivated enough to keep a clear record of all attacks and many charts were inadequately completed. It is hoped that the data resulting from this study have provided a useful definition of the term "menstrual" migraine and "menstrually related" migraine so that further studies may be more easily compared. References
1.
Dalton K. Progesterone suppositories and pessaries in the treatment of menstruation migraine. Headache 1973;13:151-9
2.
Greene R, Dalton K. The premenstrual syndrome. Br Med J 1953;1:1007-14
3.
Somerville BW. The role of progesterone in menstrual migraine. Neurology 1971;21:853-9
4.
Somerville BW. The role of estradiol withdrawal in the etiology of menstrual migraine. Neurology 1972;22:355-65
5.
Somerville BW. Estrogen withdrawal migraine. I. Duration of exposure required and attempted prophylaxis by premenstrual estrogen administration. Neurology 1975;25:239-44
6.
Somerville BW. Estrogen withdrawal migraine. II. Attempted prophylaxis by continuous estradiol administration. Neurology 1975;25:245-50
7
Bille B. Migraine in school children. Acta Paediatr Scand 1962;51(suppl 136):1-15
8.
Lance JW. Mechanism and management of headache. 4th edn. London: Butterworth Scientific 1982
9.
Welch KMA, Darnely D, Simkins RT. The role of estrogen in migraine: a review and hypothesis. Cephalalgia 1984;4:227-36
10.
Lance JW, Anthony M. Some clinical aspects of migraine. Arch Neurol 1966;15:356
11.
Greene R. Menstrual headache. In: Friedman AP ed Research and clinical studies in headache. Basel: Karger 1967;1:62-73
12.
Edelson RN. Menstrual migraine and other hormonal aspects of migraine. Headache 1985:25:376-9
13.
Mears E, Grant ECS. Anovlar as an oral contraceptive. Br Med J 1962;2:75-9
14.
Whitty CWM, Hockaday JM, Whitty MM. The effect of oral contraceptives on migraine. Lancet 1966;1:856-9
15.
Phillips BM. Oral contraceptive drugs and migraine. Br Med J 1968;2:99
16.
Larson-Cohn V, Lundberg PO. Headache and treatment with oral contraceptives. Acta Neurol Scand 1970;46:267-78
17.
Kudrow L. The relationship of headache frequency to hormone use in migraine. Headache 1975;15:36-40
18.
Dalton K. Migraine and oral contraceptives. Headache 1976;15:247-51
19.
Ryan RE St. A controlled study of the effect of oral contraceptives on migraine. Headache 1978;17:250-2
20.
Magos AL, Zilkha KJ, Studd JW. Treatment of menstrual migraine by oestradiol implants, J Neurol Neurosurg Psychiatry 1983;46(11):1044-6
21.
De Lignieres B, Vincens M, Mauvais-Jarvis P, Mas JL, Touboul PJ, Bousser I. Prevention of menstrual migraine by percutaneous oestradiol. Br Med J (Clin Res) 1986;293(6591):1540
22.
Dennerstein L, Morse C, Burrows G, Oats J, Brown J, Smith M. Menstrual migraine: a double-blind trial of percutaneous estradiol. Gynae Endocrinol 1988;2:113-20
23.
Callaghan N. The migraine syndrome in pregnancy. Neurology 1968;18:197-201
24.
Somerville BW. A study of migraine in pregnancy. Neurology 1972;22:824-8
25.
Nattero G. Menstrual headache. Adv Neurol 1982;33:215-26
26.
Stein GS. Headaches in the first post partum week and their relationship to migraine. Headache 1981;21:201-5
27.
Martin PL, Burnier AM, Segre EJ, Huix FJ. Graded sequential therapy in the menopause: A double-blind study, Am J Obst Gyn 1971;3:178-86
28.
Hay KM. A migraine survey. J R Coll Gen Pract 1973;23(127):107-11
29.
Epstein MT, Hockaday JM, Hockaday TDR. Migraine and reproductive hormones throughout the menstrual cycle. Lancet 1975;1:543-8
30.
Digre K, Damasio H. Menstrual migraine: differential diagnosis, evaluation, and treatment. Clin Obs Gyn 1987;30(2):417-30
31.
Diamond S, Dalession DJ. The practicing physician's approach to headache. Baltimore: Williams and Wilkins, 1982.
EA MacGregor, H Chia, RC Vohrah, M Wilkinson
CEPHALALGIA MacGregor EA, Chia H, Vohrah RC, Wilkinson M. Migraine and menstruation: a pilot study. Cephalalgia 1990;10:305-10. Oslo. ISSN 0333-1024 Objective: To define the term "menstrual" migraine and to determine the prevalence of "menstrual" migraine in women attending the City of London Migraine Clinic. Design: Women attending the clinic were asked to keep a record of their migraine attacks and menstrual periods for at least 3 complete menstrual cycles. Results: Fifty-five women completed the study. "Menstrual" migraine was defined as "migraine attacks which occur regularly on or between days -2 to +3 of the menstrual cycle and at no other time". Using this criterion, 4 (7.2%) of the women in our population had "menstrual" migraine. All 4 women had migraine without aura. A further 19 (34.5%) had an increased number of attacks at the time of menstruation in addition to attacks at other times of the cycle. Eighteen (32.7%) had attacks occurring throughout the cycle but with no increase in number at the time of menstruation. Fourteen (25.5%) had no attacks within the defined period during the 3 cycles studied. Discussion: A small percentage of women have attacks only occurring at the time of menstruation, which can he defined as true "menstrual" migraine. This group is most likely to respond to hormonal treatment. The group of 34.5% who have an increased number of attacks at the time of menstruation in addition to attacks at other times of the month could be defined as having "menstrually related" migraine and might well respond to hormonal therapy. The 32.7% who have attacks throughout the menstrual cycle without an increase at menstruation are unlikely to respond to hormonal therapy. The 25.5% who do not have attacks related to menstruation almost certainly will not respond to hormonal therapy. • EA MacGregor, H Chia, RC Vohrah, M Wilkinson, The City of London Migraine Clinic, 22 Charterhouse Square, London ECIM 6DX; Correspondence to Dr MacGregor. "Menstrual" migraine has been recognized since the time of Hippocrates (1). It was referred to by Fordyce in 1758 (2). Since that time many papers have suggested that migraine in women is related to fluctuation in the levels of hormones relating to the menstrual cycle (3-6). The main arguments in favour of hormones as an important influence on migraine are: 1. Migraine is equally common in both sexes (or even more common in boys (7)) up until puberty. After this time it is three times more common in women (8, 9). 2. Many women with migraine report worsening of their headaches around the time of menstruation (10-12). 3. The oral contraceptive pill may precipitate a first attack of migraine or it may worsen or improve the frequency and severity of existing attacks (13-19). 4. Oestrogen injections (7), implants (20), and percutaneous oestrogens (21, 22) have been shown to be beneficial. 5. Many women with migraine have fewer attacks during pregnancy (23-25). 6. The condition may be exacerbated in the post-partum period (26). 7. Some women have fewer attacks or cease to have attacks after the menopause (27). Most of the studies performed have been carried out by means of questionnaires sent out to women asking them if their attacks of migraine were related to menstruation (28, 29). In previous studies the prevalence of "menstrual" migraine ranges from 8% (30) to up to 70% (31). This is largely due to the fact that the definition of "menstrual" migraine is different for each study. Some definitions that have been used include: 1. An attack of common migraine (migraine without aura) occurring exclusively just before or during menstruation (not earlier than two days before menstruation and no later than the last day of the menses) (22).
2. Migraine attacks occurring predominantly during or within 2 days before menstruation (14%) (29). 3. A common migraine (migraine without aura) which occurs during the week before or the week of menstruation; the woman being headache-free for the remainder of the cycle (30). 4. Any migraine headache which occurs 3 days prior to the menstrual flow, during the time of the menstrual flow, or 3 days following (31). At the City of London Migraine Clinic we treat approximately 600 women with headache each year and it was decided to undertake a pilot study to assess the prevalence of migraine associated with menstruation in our population and provide a more specific definition of "menstrual" migraine. Patients and methods
Women attending the City of London Migraine Clinic during a six-month period who suffered from migraine with aura and/ or migraine without aura, as defined by the criteria laid down by the International Headache Society, were asked to keep a record of their migraine attacks and menstruation for at least 3 complete menstrual cycles. This was because the normal follow-up appointment is usually 3 months after the first consultation and most women attend this second assessment. Women were asked to keep the charts as a routine part of their treatment programme. Records kept by women who took the oral contraceptive pill, or who were breastfeeding, were excluded from the data analysis. The data were then analysed by recording the headaches that preceded and followed day 1 (i.e. the first day of the bleeding) of each menstrual cycle. Migraine occurring at the time of ovulation would thus be expected at day -14 for all women even if they did not have a regular 28-day cycle due to the relative constancy of the luteal phase. The pattern of migraine attacks for all three cycles was summed up on separate graphs for each woman. In this way those women having headaches associated with each phase of the menstrual cycle could be easily identified. The results were also summed up as a total of all three cycles for all 55 women. Results
Fifty-five women aged between 17 and 50 years (mean 35.8 ± SD 9.0 years) completed the study with completed records of migraine attacks over 3 menstrual cycles. Eleven women had migraine with aura (20%) and 44 had migraine without aura (80%). Fig. 1 shows the summed attacks of all headaches recorded by the 55 women over 3 complete menstrual cycles. As can be seen, there was a marked increase in migraine attacks recorded around the first day of menstruation (i.e. the start of the bleeding). There was no increase in attacks recorded at the time of ovulation. Attacks recorded at each end of the diagram are due to the variability in the length of the menstrual cycle. Six of the women (10.9%) had migraine attacks occurring only at the time of menstruation and at no other time. Of these, 4 (7.2%) had attacks in all 3 cycles recorded which occurred only between days -2 to +3 of the cycle (i.e. 2 days before menstruation to 3 days after) as in Fig. 2. This graph shows the summed attacks of these 4 patients over the 3 cycles. The other 2 patients had migraine attacks occurring also on day -4 and day +4. Only one woman had attacks of migraine within the -2 to +3 period and at the expected time of ovulation (day -14). The attacks associated with menstruation occurred in all 3 cycles, but the attack at ovulation was only recorded in one cycle. All of the above 7 women had migraine without aura. The majority of women also had attacks of migraine with aura or migraine without aura which occurred at other times of the month. Fig. 3 shows the number of headaches recorded over the 3 cycles when the 4 women with "menstrual" migraine were excluded from the results. It still shows an increase in the hum her of migraine attacks recorded at the time of menstruation. When the indi-
vidual graphs for each woman were studied, it was found that 37 women (67.3%) had attacks during all stages of the menstrual cycle over the 3 cycles studied. Of these, 19 (34.5% of total) had an increased number of attacks within the period defined for "menstrual" migraine and 18 (32.7%) had attacks throughout the cycle but with no increase in number during the defined period. Fourteen women (25.5%) had no attacks within the defined period during the 3 cycles. Discussion
"Menstrual" migraine has been the subject of much debate and many hypotheses about the cause have been formed over the years. As has been shown, the effect of menstruation seems to be most apparent between the days -2 to +3 of the menstrual cycle. There were 2 patients who had purely menstrually associated migraine but with attacks occurring just outside this range. However, it was felt that a cut-off point must be made. From the graph of the total number of headaches occurring over the 3 cycles (Fig. 1), the -2 to +3 period showed the greatest increase in headaches. For this reason it was felt that "menstrual" migraine could be defined as: "Migraine attacks which occur on or between days -2 to +3 of the menstrual cycle and at no other time". Using this definition the prevalence of "menstrual" migraine in our patient population was found to be 7.2% when 3 menstrual cycles were recorded consecutively. This compares to 14.1% found in the study by Epstein et al. (29) when the replies to a questionnaire completed adequately by 92 women still menstruating were analysed and checked by interview. These women claimed a regular relationship of their attacks of migraine to the menstrual cycle, but this was not checked with prospective records. The, original questionnaire was sent to all women over the age of 14 who had attended the Oxford Migraine Clinic over a 3-year period. so the replies were from a self-selected group. Digre and Damasio (30) found 8% of women with migraine have "menstrual" migraine using their definition of "a common migraine that occurs during the week before or the week of menstruation. the women being headache free for the remainder of the cycle". However, they also apply the term "menstrual" migraine to patients who have migraine headaches during the menstrual flow and ovulation.
Migraine attacks associated with ovulation Were not included in our definition as there did not appear to be any women in our series in whom there was a clear association between attacks of migraine and ovulation. Obviously attacks associated with ovulation would not be apparent in anovulatory cycles. Our study number may have been too small and the period of study too short to identify such a group. For the majority of women, menstruation seemed to be a further trigger factor, i.e. most women had migraine attacks occurring at any time of the month, but were still more prone to attacks around the time of menstruation. These attacks should be defined as "menstrually related" rather than as true "menstrual" migraine. Migraine attacks are triggered by several factors and menstruation must act as an additional trigger at that time. This may or may not be a specifically hormonal effect due to a direct action of the hormones or secondary to changes in the hypothalamic-pituitary axis. The effects on other biochemical pathways or even the effect of other trigger factors (dietary, sensory, stress, etc.) may also play a role. It would seem that there are only a few women for whom menstruation seems to be the sole trigger of their attacks of migraine. In summary our study identified 4 groups of women: 1. Those with "menstrual" migraine (7.2%). 2. Those with "menstrually related" migraine (34.5%). 3. Those whose attacks occur throughout the menstrual cycle but with no increase at the time of menstruation (32.7%). 4. Those whose attacks do not occur at the time of menstruation (25.5%). It was felt that further studies are required to identify the specific groups and to analyse any further differences between the groups in the light of previous studies. For example, patients identified as having "menstrual" migraine need to be studied for a much longer period of time to assess whether or not the temporal relationship of attacks to menstruation continues. Also the finding that all 4 women with "menstrual" migraine had migraine without aura needs to be corroborated with larger study numbers. The effect of other trigger factors needs to be studied-a greater link with menstruation may be found by removing as many triggers as possible (e.g. excluding dietary triggers, eating regular meals, reducing caffeine intake, etc.) or it may provide some improvement in attacks for the "menstrual" migraine group A larger series is needed to enable a firm statement to be made about the duration of increased susceptibility. This susceptibility could then be correlated with known hormonal changes and the effect of ovulation, which may have been masked in such a small group as mentioned above. The identification of the 4 distinct groups may well have an implication for the treatment of migraine in women. For example, it is most likely that hormonal treatment will be effective for the group with "menstrual" migraine and may also help the group with "menstrually related" migraine. It is unlikely that hormonal treatment will help those whose attacks are not related to menstruation. Further controlled studies will need to be undertaken to support this hypothesis. In a study such as this it is difficult to overcome the problems of a self-selected study group as only a small number of women were motivated enough to keep a clear record of all attacks and many charts were inadequately completed. It is hoped that the data resulting from this study have provided a useful definition of the term "menstrual" migraine and "menstrually related" migraine so that further studies may be more easily compared. References
1.
Dalton K. Progesterone suppositories and pessaries in the treatment of menstruation migraine. Headache 1973;13:151-9
2.
Greene R, Dalton K. The premenstrual syndrome. Br Med J 1953;1:1007-14
3.
Somerville BW. The role of progesterone in menstrual migraine. Neurology 1971;21:853-9
4.
Somerville BW. The role of estradiol withdrawal in the etiology of menstrual migraine. Neurology 1972;22:355-65
5.
Somerville BW. Estrogen withdrawal migraine. I. Duration of exposure required and attempted prophylaxis by premenstrual estrogen administration. Neurology 1975;25:239-44
6.
Somerville BW. Estrogen withdrawal migraine. II. Attempted prophylaxis by continuous estradiol administration. Neurology 1975;25:245-50
7
Bille B. Migraine in school children. Acta Paediatr Scand 1962;51(suppl 136):1-15
8.
Lance JW. Mechanism and management of headache. 4th edn. London: Butterworth Scientific 1982
9.
Welch KMA, Darnely D, Simkins RT. The role of estrogen in migraine: a review and hypothesis. Cephalalgia 1984;4:227-36
10.
Lance JW, Anthony M. Some clinical aspects of migraine. Arch Neurol 1966;15:356
11.
Greene R. Menstrual headache. In: Friedman AP ed Research and clinical studies in headache. Basel: Karger 1967;1:62-73
12.
Edelson RN. Menstrual migraine and other hormonal aspects of migraine. Headache 1985:25:376-9
13.
Mears E, Grant ECS. Anovlar as an oral contraceptive. Br Med J 1962;2:75-9
14.
Whitty CWM, Hockaday JM, Whitty MM. The effect of oral contraceptives on migraine. Lancet 1966;1:856-9
15.
Phillips BM. Oral contraceptive drugs and migraine. Br Med J 1968;2:99
16.
Larson-Cohn V, Lundberg PO. Headache and treatment with oral contraceptives. Acta Neurol Scand 1970;46:267-78
17.
Kudrow L. The relationship of headache frequency to hormone use in migraine. Headache 1975;15:36-40
18.
Dalton K. Migraine and oral contraceptives. Headache 1976;15:247-51
19.
Ryan RE St. A controlled study of the effect of oral contraceptives on migraine. Headache 1978;17:250-2
20.
Magos AL, Zilkha KJ, Studd JW. Treatment of menstrual migraine by oestradiol implants, J Neurol Neurosurg Psychiatry 1983;46(11):1044-6
21.
De Lignieres B, Vincens M, Mauvais-Jarvis P, Mas JL, Touboul PJ, Bousser I. Prevention of menstrual migraine by percutaneous oestradiol. Br Med J (Clin Res) 1986;293(6591):1540
22.
Dennerstein L, Morse C, Burrows G, Oats J, Brown J, Smith M. Menstrual migraine: a double-blind trial of percutaneous estradiol. Gynae Endocrinol 1988;2:113-20
23.
Callaghan N. The migraine syndrome in pregnancy. Neurology 1968;18:197-201
24.
Somerville BW. A study of migraine in pregnancy. Neurology 1972;22:824-8
25.
Nattero G. Menstrual headache. Adv Neurol 1982;33:215-26
26.
Stein GS. Headaches in the first post partum week and their relationship to migraine. Headache 1981;21:201-5
27.
Martin PL, Burnier AM, Segre EJ, Huix FJ. Graded sequential therapy in the menopause: A double-blind study, Am J Obst Gyn 1971;3:178-86
28.
Hay KM. A migraine survey. J R Coll Gen Pract 1973;23(127):107-11
29.
Epstein MT, Hockaday JM, Hockaday TDR. Migraine and reproductive hormones throughout the menstrual cycle. Lancet 1975;1:543-8
30.
Digre K, Damasio H. Menstrual migraine: differential diagnosis, evaluation, and treatment. Clin Obs Gyn 1987;30(2):417-30
31.
Diamond S, Dalession DJ. The practicing physician's approach to headache. Baltimore: Williams and Wilkins, 1982.
