Redefining menstrual migraines: New criteria for accurate diagnosis and improved treatment response

By Dr. Chinta SidharthanReviewed by Benedette Cuffari, M.Sc.May 17 2023

In a recent study published in JAMA Network Open, researchers evaluate the clinical characteristics and treatment response of menstrual migraines to formulate new criteria for the diagnosis of menstrual migraines.

Study: Population Based Characterization of Menstrual Migraine and Proposed Diagnostic Criteria. Image Credit: fizkes / Shutterstock.com

Background

Migraines are one of the most common causes of years lost to disability across the world. Although migraines affect people of all ages, women are more frequently affected than men.

Among women, the occurrence of migraines varies across different stages of life, from puberty to menopause; however, it is the most prominent cause of healthy years lost among women during their childbearing years. In fact, about 25% of women experience migraine attacks that are linked to menstruation.

There are several issues with the current International Classification of Headache Disorders, Third Edition (ICHD-3) criteria for diagnosing menstrual migraines. For example, the lack of clarity regarding the frequency and timing of migraines, especially in cases of high-frequency episodic and chronic migraines, leads to the misdiagnosis of menstrual migraines.

Thus, there remains an urgent need to reassess the clinical characteristics of menstrual migraines to formulate new diagnostic criteria for their accurate diagnosis and treatment.

About the study

In the present case-control study, researchers selected a cohort of participants belonging to the Danish Migraine Population Cohort, which is representative of individuals with migraines in the Danish population. Participants were required to complete a validated 105-item questionnaire on diagnostic headaches, which comprised, among other components, physical and self-perceived mental health component scales.

The physical health scale assessed general health, physical functioning, bodily pain, and vitality, while the mental health scale evaluated emotional functioning, general health, social functioning, and vitality. The assessment also included a visual analog scale, which evaluated pain intensity during migraine attacks. Treatment outcomes for analgesics and triptans were assessed on a scale of zero to 10, ranging from 50% to complete pain relief.

Study participants with pure menstrual, rare pure migraines, or menstrually-related migraines were grouped into the menstrual migraine cohort.

Comparatively, those who had migraines that were not related to menstruation were grouped into the non-menstrual migraine cohort. The non-menstrual migraine group also included women with chronic and high-frequency episodic migraines.

Menstrual migraine features were assessed using logistic regression analyses and descriptive statistics. Additionally, a simulation analysis was conducted to determine the risk of random misclassification of menstrual migraines over three menstrual cycles, with 100,000 permutations analyzing random migraine attacks.

Results

The current criteria for diagnosing menstrual migraines were not adequate for capturing the severity of menstrual migraines. Furthermore, the analysis revealed that the clinical characteristics of menstrual migraines were quantitatively different from those of non-menstrual migraines. Thus, new criteria for diagnosing menstrual migraines are crucial.

The frequency of symptoms associated with migraines was higher for menstrual migraines, as were the severity and frequency of migraine attacks. Non-migraine headaches were also less frequent in individuals with menstrual migraines than those with non-menstrual migraines, with menstrual migraines responding better to triptan treatment. Menstrual migraines also improved during late pregnancy but reappeared faster during the post-partum period.

Individuals with menstrual migraines related to hormonal contraceptives had fewer migraines with aura or sensory symptoms as compared to individuals with migraines associated with spontaneous menstruation.

The criteria proposed by the researchers addressed some of the major limitations associated with the current diagnostic criteria for menstrual migraines. Since the frequency of migraine attacks for women who experienced rare pure menstrual migraines was lower than the two- or three-menstrual-cycle cut-off, these cases were excluded from the menstrual migraine diagnosis, despite the clear association between menstruation and the migraine. Therefore, cases of rare pure menstrual migraine were now included in the menstrual migraine diagnosis.

Cases of high-frequency episodic and chronic migraines were excluded from the menstrual migraine diagnosis. The new diagnostic criteria also specified the start time of the migraine attack during the menstrual cycle and allowed for more than one migraine attack during a single menstrual period.

Conclusions

Menstrual migraines have certain characteristics distinct from those associated with non-menstrual migraines, which could be used to formulate new diagnostic criteria. In the current study, menstrual migraines were associated with a higher frequency of symptoms associated with migraines, a lower occurrence of non-migraine headaches, increased severity and frequency, and a better response to triptan treatment.