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Acute treatment and prevention of menstrually related migraine headache

Evidence-based review

From the Division of Neurology (T.P.), University of Toronto; private practice (W.J.D.), Toronto, Ontario, Canada; and Department of Neurology (D.D.), Mayo Clinic College of Medicine, Scottsdale, AZ.

Address correspondence and reprint requests to Dr. Tamara Pringsheim, Movement Disorders Centre, Toronto Western Hospital, 399 Bathurst Street, Toronto ON M5T 2S8 Canada tamara.pringsheim{at}utoronto.ca

Menstrually related migraine (MRM) headache is common in women and associated with substantial disability. Compared to nonmenstrual migraine, MRM attacks are more severe, longer in duration, and have a poorer response to analgesics. The purpose of this guideline is to provide a systematic review and meta-analysis of the existing therapy trials for MRM and evidence-based recommendations for acute and short-term preventive treatment of MRM headache. Prospective, double-blind, randomized controlled trials of any pharmacologic agent for the symptomatic relief or prevention of MRM headache were included in the guideline. The main outcomes considered were the pain response and pain-free response at 2 hours for acute treatment trials, and the incidence of MRM or the number of days on which MRM attacks occurred for short-term prevention trials. Nineteen trials were included in the analysis. The US Preventive Services Task Force quality criteria were used to assess trial quality and to grade recommendations. Based on the evidence, grade B recommendations can be made for the use of sumatriptan 50 and 100 mg, mefenamic acid 500 mg, and rizatriptan 10 mg for the acute treatment of MRM. For the preventive treatment of MRM, there are grade B recommendations for the perimenstrual use of transcutaneous estrogen 1.5 mg, frovatriptan 2.5 mg twice daily, and naratriptan 1 mg twice daily. Choosing among treatment strategies must be based on clinical considerations.

GLOSSARY: AAN = American Academy of Neurology; AE = adverse event; AHS = American Headache Society; ANA = American Neurological Association; ARR = absolute risk reduction; IHS = International Headache Society; ITT = intent-to-treat; MAOI = monoamine oxidase inhibitor; MC = menstrual cycles; MRM = menstrually related migraine; PMM = pure menstrual migraine; RCT = randomized controlled trial; RD = risk differences; USPSTF = US Preventive Services Task Force.

Supplemental data at www.neurology.org

Disclosure: Dr. Dodick has provided consulting services for GSK, Merck, Allergan, Endo, Pfizer, Eli Lilly, Addex, Solvay, Neuralieve, and St. Jude, and he has provided research support for Advanced Neurostimulation Systems (ANS) and Medtronic. The other authors report no disclosures.

Received July 30, 2007. Accepted in final form October 16, 2007.