Menstrual migraine

•Slightly less than half of women with migraine report that menstruation is an important trigger of headache episodes. However, it is rare that menstruation is the only trigger for a patient and its importance as a trigger may be overemphasized. Accurate diagnosis requires a prospectively kept diary of information showing a consistent and mechanistically valid temporal correlation between migraine attacks and menstrual periods.•Abnormal central nervous system response to normal fluctuations in hormones is the likely underlying cause of menstrual migraine. Patients with menstrual migraine do not generally have hormonal abnormalities.•Currently available abortive therapy works well for menstrual-related migraine attacks. For the small subset of women for whom this is not the case, and whose menstrual periods and associated headaches are predictable, pre-emptive treatment of the expected headache with scheduled perimenstrual use of a number of agents can be helpful.•A hormonal trigger for migraine headache does not mean that treatment must also be hormonal in nature. Choice of therapy depends on the frequency of menstrual migraine, predictability of menstrual periods, patient preference, and cost.•For the small group of women with refractory menstrual migraine, hormonal therapy can be tried, with the understanding that the quality of evidence for these interventions is low and their risk to benefit ratios not established.•The perimenstrual use of triptan medications is currently being investigated forthe treatment of menstrual migraine. Preliminary results are inconclusive, and until further evidence regarding the efficacy, safety, practicality, and cost effectiveness of this approach is available, their routine use in this manner for menstrual migraine is not recommended.