Comparing Perimenstrual and Nonperimenstrual Migraine Attacks Using an e-Diary

Abstract

BackgroundEndogenous and exogenous female sex hormones are considered important contributors to migraine pathophysiology. Previous studies have cautiously suggested that perimenstrual migraine attacks have a longer duration and are associated with higher disability compared to non-perimenstrual attacks, but they showed conflicting results on acute therapy efficacy, pain intensity, and associated symptoms.ObjectivesTo compare perimenstrual and non-perimenstrual migraine attack characteristics and assess premenstrual syndrome (PMS) in women with migraine.MethodsWomen with migraine were invited to complete a headache E-diary. Characteristics of perimenstrual attacks and non-perimenstrual attacks were compared. The primary outcome was attack duration. Secondary outcomes were headache intensity, accompanying symptoms, acute medication intake and pain coping. Mixed effects models were used to account for multiple attacks within patients. PMS was assessed in those without hormonal contraceptives. Subgroup analyses were performed for women with menstrually related migraine (MRM) and non-menstrually related migraine (non-MRM), and women with a natural menstrual cycle and women using hormonal contraceptives.ResultsA representative group of n=500 participants completed the E-diary for at least one month. Perimenstrual migraine attacks (n=998) compared with non-perimenstrual attacks (n=4097) were associated with longer duration (20.0 vs 16.1 hours, 95%CI [0.2-0.4]), higher recurrence risk (OR 2.4 [2.0-2.9]), increased triptan intake (OR 1.2 [1.1-1.4]), higher headache intensity (OR 1.4 [1.2-1.7]), less pain coping (mean difference -0.2 [-0.3- -0.1]), more pronounced photophobia (OR 1.3 [1.2-1.4]) and phonophobia (OR 1.2 [1.1-1.4]) and less aura (OR 0.8 [0.6-1.0]). In total 396/500 women completed the diary for ≥3 consecutive menstrual cycles, of whom 56% (221/396) fulfilled MRM criteria. Differences in attack characteristics became more pronounced when focusing on women with MRM and women using hormonal contraceptives. Prevalence of PMS was not different for women with MRM compared to non-MRM (11% vs. 15%).DiscussionThe longer duration of perimenstrual migraine attacks in women (with MRM) is associated with higher recurrence risk and increased triptan use. This may increase the risk of medication overuse and emphasizes the need to develop female-specific prophylactic treatment.

Efficacy of lasmiditan for the acute treatment of perimenstrual migraine

“…This supports the observation that perimenstrual migraine is characterized by being relatively more difficult to treat acutely (13)(14)(15)(16). In comparison to the original cohort studies in which 10.4% and 4.3% of placebo-treated patients achieved 24-hour sustained headache pain freedom (18,22), only 2.5% of patients with perimenstrual attacks in the placebo group achieved 24-hour sustained headache pain freedom, supporting previous observations that perimenstrual migraine attacks are associated with a higher risk of recurrence (16,(26)(27)(28). While some countries limit lasmiditan to a single dose every 24 hours, other countries allow a second dose for relapse, to a maximum of 200 mg per 24 hours.…”

Place of next generation acute migraine specific treatments among triptans, non-responders and contraindications to triptans and possible combination therapies

“…This may be the result of a longer attack duration, which may be attributed to sex hormone influences (24). That perimenstrual migraine attacks in women have a longer attack duration, higher recurrence risk and increased triptan intake, support this hypothesis (27).…”

Serum CGRP in migraine patients using erenumab as preventive treatment

“…The clinical response to erenumab was monitored using a validated daily headache e-diary [ 11 , 15 , 16 ]. This diary contains questions on the presence of headache, headache characteristics, accompanying symptoms and the use of acute migraine medication.…”