What is a catamenial migraine?Catamenial migraine is a migraine induced by the fluctuation of hormones during the menstrual cycle. They usually appear just before or just after menstruation. A distinction is made between pure menstrual migraine , which appears only at the time of menstruation; migraine induced by menstruation where in this specific case the patient also suffers from migraine at other times of the cycle. Catamenial migraine is therefore summarized as follows:
- Pure catamenial migraine : the patient suffers from a migraine once a month at the time of menstruation
- Induced catamenial migraine: the patient regularly suffers from migraine during the cycle, but mainly during menstruation
Diagnosis of catamenial migraine
To define catamenial migraines and establish an accurate diagnosis, attacks must occur two days before the onset of menstruation or up to three days after . Of course , the other diagnostic criteria for migraine must be respected : unilateral and throbbing headaches, which evolve by attack, associated with nausea or vomiting, sensitivity to light or noise and aggravated by physical activity.
Catamenial migraine with aura
Whether in pure menstrual migraine or in induced catamenial migraine, the patient may associate migraine auras .
Migraine aura is a particular subtype of migraine in which the patient describes associated neurological disorders . Most often it is visual disturbances, such as the appearance of hatched lines in the visual field of small spots, we then speak of ophthalmic migraine . The migraine aura can, however, manifest itself through other symptoms such as speech disorders, motor or even sensory disorders. The migraine aura is the consequence of a massive excitation of neurons that spread like a wave or a wave on the surface of the cortex. This violent activation of certain neurons then causes the transient neurological symptoms that are associated with migraine aura .
It was only in 2018 that catamenial migraine with aura was officially included among the list of headaches . To validate the diagnosis of catamenial migraine, it is necessary that the patient produces a migraine at least twice every three cycles .
How to recognize a catamenial migraine?
It is easy to recognize a catamenial migraine when it is said to be pure . That is to say when it occurs only during menstruation . However, when the patient has regular migraines, it is sometimes difficult to distinguish catamenial migraines from other migraines . Even if this point may seem futile, we will see later that the management of catamenial migraine can be different from traditional migraine. It is therefore important to note whether some migraines are specific to the menstrual cycle .
For this, your doctor will advise you to follow a migraine diary . This diary must list all the information concerning your migraine attack, namely: the date and time of onset of the attack, the intensity of the attack, the possible triggering factor and the treatment taken. The analysis of this migraine diary will make it possible to make the link with the menstrual cycle of the woman and to see if migraines appear regularly near the day of the rules or if the migraines close to the menstruation are of an intensity more important than the others.
Recognizing a catamenial migraine makes it possible to better understand the treatment of migraine, we will see later the fundamental role that hormones can play in these crises . It is however possible to modulate or limit the hormonal variation thanks to contraceptive pills for example. Recognizing catamenial migraine therefore makes it possible to precisely adapt a specific treatment.
What Causes Catamenial Migraine
The causes of catamenial migraine are essentially hormonal . It has been shown in several studies that menstrual migraines are the consequence of the significant variation in estrogen . Remember that migraine is an intolerance of the brain to change . Any significant variation can lead to the onset of a migraine attack . It is for this reason that thetriggering factors of migraine are so numerous (diet, stress, sleep, climatic environment, etc.). The sudden change in hormones can be considered by the brain as a change , and therefore participate in the triggering of a migraine attack.
The role of estrogen and progesterone hormones
The figure below shows how estrogen changes during the menstrual cycle . It is observed that during the phase of menstruation, the level of progesterone estrogen decreases considerably.
If estrogen is mainly incriminated in the onset of migraine attacks, several studies tend to show that progesterone could also play a role .
As part of a study on women's health were assessed whether the hormone level or variations differ between women with migraine compared to women in a control group . In order to explore the hypothesis that women with migraine have distinct hormonal profiles , they compared daily hormone peaks and levels between all of these women across the menstrual cycle. Interestingly, in this study, there was no significant difference between migraineurs and controls in estrogen peaks or average daily levels. In contrast, there is a significant difference between the two groups in the rate of estrogen decline , particularly at the end of the luteal phase , just after ovulation.
In addition, in migraineurs, the rate of estrogen decline does not distinguish between cycles with and without acute headache. This finding suggests that a neuroendocrine vulnerability characterizes female migraineurs and may facilitate the onset of the migraine attack . Interestingly, these pathophysiological considerations regarding migraineurs versus controls might also underlie the more specific condition of menstrual migraineurs. On the other hand, no clear relationship between progesterone fluctuations during the menstrual cycle and migraine attacks was found in this study.
Estrogens also implicated in endometriosis
The variation of ovarian hormones is also implicated in the modulation of chronic pain and particularly in endometriosis. Several studies have shown the protective effect of estrogen against the onset of pain. They have natural anti-inflammatory activity . It is also for this reason that their decrease during the menstruation phase can facilitate the appearance of inflammation and therefore of acne or endometriosis, etc. In the case of migraine, the variation in estrogens can have a double impact : on the one hand, resulting in a significant variation for the brain and therefore being considered as a triggering factor for migraine , and on the other hand, the reduction in their rate. facilitates the onset of inflammation and therefore promotes the intensity of migraines.
Estrogens influence prostaglandins in catamenial migraine
It has been shown that the decrease in estrogen is likely to lead to a massive release of prostaglandins . Prostaglandins are immune system proteins that promote inflammation . In women, they are massively released during the luteal phase of the cycle, that is to say just after ovulation. During the period of menstruation, the amount of estrogen is at its lowest and therefore the release of prostaglandins is important, which promotes the appearance of inflammation and therefore migraines .
The role of CGRP and neuropeptides in menstrual migraine
The massive release of prostaglandins linked to the drop in estrogen levels will cause the massive release of neuropeptides . Among them we can note substance P or the gene linked to the calcitonin peptide (CGRP). These neuropeptides are involved in triggering migraine attacks and maintaining pain . They are released by a special system called the trigeminovascular system . This system is involved in the innervation of the meninges which is the envelope of the brain and its blood vessels .
During a migraine attack, this system will massively release these neuropeptides which will cause strong inflammation and at the same time vasodilatation , that is to say a significant dilation of the blood vessels. This inflammatory reaction on the meninges is at the origin of the pain felt by the patient . Hormonal fluctuations in women have been shown to directly influence the amount of CGRP contained in the trigeminovascular systems.
A study has also shown that the level of CGRP found in blood plasma is significantly higher in women than in men . This confirms the correlation with the menstrual cycle and may potentially explain why women are more prone to migraines than men .
How many women suffer from catamenial migraines?
Several studies have attempted to quantify the number of female migraine sufferers with catamenial migraine . It is known that 15 to 20% of the population suffers from migraine, among these patients two thirds are women . A recent study established in Norway on 5000 female migraine sufferers showed that 6% of women suffered from catamenial migraine. 6.1% suffered from catamenial migraine without aura and 0.6% with aura. If we consider all women, the prevalence of catamenial migraine would be around 1%.
Menstrual migraine during a woman's lifetime
The relationship between the menstrual cycle and catamenial migraines may change over the course of a woman's reproductive life . A study reports that catamenial migraines appear after the age of 30 preferably. During pregnancies , women who suffer from catamenial migraines have reported much more intense migraines at the beginning of this one. During the postpartum this observation is identical. As in the majority of women, the second and third trimester phase of pregnancy is often a sign of a significant reduction in the frequency of migraine attacks . This is hormonal stability with a high dose of estrogen that protects the woman from the appearance of new crises.
Significant fluctuations in estrogen levels occur during perimenopause , which is when menopause begins to set in. These fluctuations lead to a significant decrease in estrogen levels . As a result, the majority of women with migraine report seeing an intensification of migraine attacks during this period. Fortunately, when menopause sets in, hormonal stability usually leads to a decrease in the frequency of seizures .
How to treat catamenial migraine?
Crisis treatment and basic treatment
Generally catamenial migraine attacks are more difficult to respond to usual migraine attack treatments . Additionally, there is currently no specific treatment for catamenial migraine . However, the intensity of the pain requires the implementation of an effective treatment. For this reason, treatment for seizures will always be prescribed to the patient. Triptans are the most common treatment. It will also be necessary to add a preventive treatment, which is also called basic treatment or prophylactic treatment of migraine .
Unlike the treatment of seizures which is taken to stop it when it happens, the background treatment aims to gradually reduce the frequency of seizures . Generally a basic treatment must be taken every day and is evaluated over three to six months. Studies have shown that the combination of a triptan and a nonsteroidal anti-inflammatory drug would be much more effective in the case of catamenial migraines. The addition of anti-inflammatories then compensates for the anti-inflammatory effect of estrogens.
The pill and contraceptives
The use of hormonal contraceptives such as the pill or certain IUDs and a plan can play on the fluctuation of hormones . For this reason it is essential that the patient consults her doctor or her gynecologist in order to prescribe a contraceptive that will stabilize estrogen and hormonal variations as much as possible. This phase of the treatment sometimes requires several months of adaptation and it is very rare to succeed on the first try. However, it is important to persevere, because the benefit can be considerable .