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BAL HARBOUR, FLA. -- Women who get migraines tend to overestimate the association between their headaches and menstruation, Dr. Elizabeth W. Loder said at the annual meeting of the American Headache Society.

Even when there is a link between menstruation and migraines, the headaches are neither more severe nor more difficult to treat than migraines occurring at other times of the month, contrary to popular belief. Don't jump to the use of estrogen or other hormonal manipulation to treat menstrual migraine, because standard therapies usually work just fine, said Dr. Loder, director of the headache management program at Spaulding Rehabilitation Hospital, Boston.

About 60% of women with migraine reported that their headaches were more likely to occur around the menstrual period in a 1985 survey. Patient self-reports are 45%-69% higher than actual rates of menstrually associated migraine found in carefully controlled prospective studies, Dr. Loder said.

The menstrual period is an easy target. It's a recurring event carrying a lot of cultural significance. "Anything that happens around it tends to be blamed on it. You need to have at least a modicum of suspicion and conservatism before you call everybody a menstrual migraineur," she said.

Before embarking on any special treatment aimed at menstrual migraine, have the patient keep track of her menstrual period and her headache attacks for 2-3 months. Many diaries will show that migraines do regularly occur around menstruation but also commonly occur at other times of the month. "If you had accepted at face value her report that she had menstrual migraine and embarked on special treatment, you would really be missing the bulk of her headache problem," Dr. Loder emphasized.

Despite perceptions by patients and physicians that menstrual migraines hurt more, last longer, and are more resistant to treatment than other migraine attacks, analyses of large databases from many treatment trials unequivocally debunk these myths.

NSAIDs can treat the headache and menstrual cramping. All the other over-the-counter treatments and standard prescription therapies for migraine--including all the approved triptans and some that are not yet on the market--are equally effective for menstrual and nonmenstrual migraines.

If a patient diary verifies that the woman's menstrual cycle is predictable, menstrually associated migraine may be prevented or its severity lessened by "miniprophylaxis" with 550 mg of naproxen sodium given 5 days perimenstrually, studies show. Start the drug 1-2 days before the expected onset of headache. Note that the migraine often starts a day or so before bleeding starts, she said.

"I suspect that any of the anti-inflammatory drugs would work in that role," Dr. Loder added.

Only anecdotal reports back the use of [beta]-blocker drugs, tricyclic antidepressants, and other migraine preventative therapies for miniprophylaxis of menstrually associated migraine.

Alternatively, perimenstrually increasing the dose of other preventative agents being used during the rest of the month may help prevent or decrease menstrually associated migraine.

Small, open-label trials of sumatriptan or naratriptan for miniprophylaxis of menstrually associated migraine produced mixed results.

Studies of hormonal therapies for menstrual migraine also have produced conflicting results. One study of oral estrogen found no benefit. Estradiol implants helped treat the headache but changed the menstrual cycle length, making it difficult to know when to treat. Data on subcutaneous estradiol were mixed.

Trials of estrogen patches suggest that a 100-[micro]g patch may help prevent menstrually associated headache but 50- or 25 [micro]g patches do not, she said.

Extended use of monthly oral contraceptives makes sense mechanistically to prevent menstrually associated migraine, but no controlled studies have looked at this strategy. A number of nonestrogen hormonal treatments have been advocated based on anecdotes or small, open-label studies in refractory patients. The unknown risk-benefit ratio for these treatments should preclude their use, she said.