Menstrual Migraine

Casebank History
1

It's not actually a migraine.

Who are you:
You are an FY2 in GP surgery

Who the patient is:
Laura Flick, a 17 year old young girl came to the clinic with complain of a headache.

What you must do:
Talk to the patient, take focused history, give management and address her concerns.

SOTCRAS

  • Headache since one year
  • Dull pain
  • Starts 2 - 3 days before periods and stops after 2 days into periods.
  • Paracetamol and ibuprofen does not work
  • Affects school

Ask

  • Period history: Do you have any pain with periods?
  • Are you sexual active?
  • Do you use any form of contraception?

PMH

  • Blood disorder
  • Blood thinner
  • Kidney disease

Rule out: PMS (breast tenderness, loss of appetite, mood swings, trouble sleeping, low sex drive), PMS not same as MM

Examination

  • OBS/GPE
  • Neurological
  • Fundoscopy

Investigation: FBC(anemia), CRP, ECR

Diagnosis: Its a type of headache that doctors believe is due to changes in your hormones throughout the menstrual cycle.

Management

  • Intranasal sumatriptan
    • You take it 2 days before period and 3 days after bleeding starts
    • If age less than 18, oral sumatriptan can’t be given.
  • Migraine diary: you note down
    • Period history: Start and end date
    • Type of symptoms experienced
    • Number of headaches
  • Follow up after 2-3 cycles.
  • Once your diagnosis is confirmed we’ll offer long term treatment ie COCP without break.
  • COCP contraindicated in migraine with aura
  • Also can use estrogen hormonal patches
  • Oestrogen has dual benefit: work as contraception and Rx for MM
  • Exercise and healthy diet

P: I want to go on a swimming holiday to Australia, can you give me pills to stop periods?
Give combined pills without break, first 3 months then repeat 6 monthly prescription

Safety net: Vomiting, Rash

3

You are fy2 in GP practice. A 21 year old young girl came to the clinic with
complain of a headache.Talk to her ,take history,tell management and
address her concerns.

Patient details
● A 21 year old young girl came with complain of headache,which
started gradually, continuous, all around the head, not radiating
anywhere ,no associated symptoms like blurry vision, nausea or
vomiting
● Her headache usually starts before her period and stops about 2
days into period, she tried ibuprofen and paracetamol but it didn’t
help
● No past medical and medication history, or family history of similar
symptoms
● Her menstruation regular,otherwise fit and well

● no smoking or alcohol habit, diet normal

Concerns
Is this due to a brain tumor?

Station Approach
● Greet and confirm identity
● Explore the headache,do ODPARA, ask associated symptoms
● Do differentials: red flags (glaucoma, SAH, meningitis, encephalitis,
tension headache, GCA etc)
● ask premenstrual symptoms questions(breast tenderness,loss of
appetite,mood swing,trouble sleeping,low sex drive)
● ask menstrual history, ask headache relation to menstrual period
● sexual history, pills, mood: not active , mood fine
● Do ICE
● verbalize examination and investigation
● Explain menstrual migraine which precipitated by period
● Send home with medicine and advice
● investigation:Routine bloods,ESR and CRP
● Treatment: sumatriptan during the attack of migraine as ibuprofen
and paracetamol are not working
● Advice
● 1. keeping a diary of period and headache
● 2. Once the relationship between the headache and menstrual period
has been confirmed then she needs to start on COCP to be taken
continuously.(cocps are only given if the periods are irregular so the
headache is unpredictable. it’s not routinely given)

● 3. when she will ask about weight gain, tell her about dietitian and
exercise
● 4. Follow up in three months
● Safety netting