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Diary data from 155 women were analyzed using within-woman analysis. Compared with all other times of the cycle, migraine was 1.7 times more likely to occur during the 2 days before menstruation and 2.1 times more likely to be severe and 2.5 times more likely to occur during the first 3 days of menstruation and 3.4 times more likely to be severe. This confirms that migraine at menstruation is different from nonmenstrual attacks, even within individuals.

Objective: To investigate the association between urinary hormone levels and migraine, with particular reference to rising and falling levels of estrogen across the menstrual cycle in women with menstrual and menstrually related migraine. Methods: Women with regular menstrual cycles, who were not using hormonal contraception or treatments and who experienced between one and four migraine attacks per month, one of which regularly occurred on or between days 1 Ϯ 2 of menstruation, were studied for three cycles. Women used a fertility monitor to identify ovulation, conducting a test each day as requested by the monitor, using a sample of early morning urine. Urine samples were collected daily for assay of estrone-3-glucuronide, pregnanediol 3-glucuronide, follicle-stimulating hormone, and luteinizing hormone. All women kept a daily migraine diary and continued their usual treatment for migraine. Results: Of 40 women recruited, data from 38 women were available for analysis. Compared with the expected number of attacks, there was a significantly higher number of migraine attacks during the late luteal/early follicular phase of falling estrogen and lower number of attacks during rising phases of estrogen. Conclusion: These findings confirm a relationship between migraine and changing levels of estrogen, supporting the hypothesis of perimenstrual but not postovulatory estrogen "withdrawal" migraine. In addition, rising levels of estrogen appear to offer some protection against migraine. NEUROLOGY 2006;67:2154-2158 During the female reproductive years, migraine is up to three times more common in women than in men of similar age. 1 This sex difference is generally considered to be due to the additional hormonal trigger in women. In specialist clinics and in populationbased studies, 50% of women report an association between migraine and menstruation. 2,3 The peak time for migraine is on or between 2 days before the start of menstruation and the first 3 days of bleeding. [4][5][6][7][8] Identification of the underlying mechanisms of menstrual migraine could enable more effective treatment strategies to be developed. However, despite clinical evidence for the effect of hormonal events, the pathophysiology remains poorly understood.The main hormones considered have been progesterone and estrogen. Levels of both these hormones fall in the late luteal phase of the menstrual cycle, preceding the increase in menstrual attacks of migraine.Evidence for the importance of progesterone in migraine is conflicting. 9-12 A greater body of evidence suggests that migraine is associated at least in some women, with the "withdrawal" of exogenous and endogenous estrogen. [13][14][15][16][17][18][19] However, results from studies assessing serum or urinary hormones levels and headache risk are based on limited data. Further, headache risk has been analyzed according to standard menstrual, follicular, and luteal phases of the menstrual cycles rather than specifically analyzing risk during rising and falling hormone phases. 20 We here present...

The Aids to Management are a product of the Global Campaign against Headache, a worldwide programme of action conducted in official relations with the World Health Organization. Developed in partnership with the European Headache Federation, they update the first edition published 11 years ago.The common headache disorders (migraine, tension-type headache and medication-overuse headache) are major causes of ill health. They should be managed in primary care, firstly because their management is generally not difficult, and secondly because they are so common. These Aids to Management, with the European principles of management of headache disorders in primary care as the core of their content, combine educational materials with practical management aids. They are supplemented by translation protocols, to ensure that translations are unchanged in meaning from the English-language originals.The Aids to Management may be individually downloaded and, as is the case for all products of the Global Campaign against Headache, are available without restriction for non-commercial use.Electronic supplementary materialThe online version of this article (10.1186/s10194-018-0899-2) contains supplementary material, which is available to authorized users.

In the general population samples we surveyed, there was a 5% to 12% prevalence of migraine across 5 different countries. As reported from previous epidemiologic studies, we found that many migraineurs still do not consult a physician. Despite high levels of disability, as assessed by MIDAS scores and evidenced by the need for bed rest during attacks, many migraineurs continue to treat their headaches with simple analgesics, which, if ineffective, leads to dissatisfaction with treatment. Patients desire a medication with high efficacy and a rapid onset of action, and an orally disintegrating tablet such as that used for the new zolmitriptan formulation, is a favored formulation and route of administration.

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A small percentage of women have attacks only occurring at the time of menstruation, which can be 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.