Throughout the childbearing years, migraine headache is two to three times more prevalent in women than in men. In addition, migraine has special features in women, principally menstrually-synchronized migraine attacks, safety issues for using oral contraceptives, and changes associated with pregnancy and menopause. Matharu and colleagues review these and other aspects of migraine in women.

Although 60 percent of women with migraine report that attacks are more likely to occur at menstruation, only 14 percent have migraine exclusively with the menstrual cycle, almost always on the first two days of menstruation. Menstrual migraine attacks do not appear to differ from other migraine headaches but are less likely to be preceded by aura. A headache diary may be necessary to confirm the relationship between migraine and menstruation, especially if periods are irregular. Prophylactic medication for two days before the anticipated onset of menstruation is recommended, using naproxen or fenoprofen. Mefenamic acid is recommended if the patient also has dysmenorrhea. Perimenstrual estrogen supplementation, such as the 100-mcg transdermal estrogen patch, also can be effective. In severe cases, danazol, tamoxifen, and bromocriptine have been used.

In women with migraine, the headaches may worsen (18 to 50 percent), improve (3 to 35 percent), or not change (39 to 65 percent) when they are taking combined oral contraceptives (OCPs). If migraine occurs, it is most likely to be at times of estrogen withdrawal. This result can be countered by continuous use of OCPs, but women may find the associated irregular bleeding unacceptable. The most serious concern in women with migraine who are taking OCPs is increased risk of ischemic stroke. The risk is small, increasing from a rate of 5 to 10 per 100,000 women-years in women without migraine to a rate of 17 to 19 per 100,000 women-years in those with migraine. The risk is greatest in women with migraine with aura and in those with additional risk factors, such as new persisting headache or new-onset migraine aura. The authors recommend screening women for risk factors, using the lowest possible dosage of estrogen, and avoiding the use of OCPs in women who have migraine with aura.

Approximately 60 to 70 percent of women with migraine experience relief during pregnancy. Treatment options are restricted in attacks that occur in the pregnant patient because ergotamines and triptans are not recommended in this group. Acetaminophen may be used for analgesia. Ibuprofen and naproxen are not recommended close to delivery but may provide relief earlier in pregnancy. Several antiemetics, such as metoclo-pramide, chlorpromazine, prochlorperazine, and promethazine, are regarded as safe for use during pregnancy.

Physiologic menopause is associated with improvement in migraine in about two thirds of women, but perimenopause can be a time of severe and frequent attacks. Migraine appears to worsen after surgical menopause. The risk of stroke does not appear to be increased with use of hormone replacement therapy (HRT) in women with migraine. Migraine may worsen or improve with HRT. If symptoms are severe and frequent, use of low-dose, continuous regimens based on synthetic ethinyl estradiol is recommended.