I'd like to know more about the link between menstruation and migraine. My friend -- a migraneur like myself -- says her cycle brings relief from her headaches. But I'm just the opposite; I have killer migraines right around the time of my period. Why would we be different in this regard?

--Karen

The situation you describe is common. About 60 percent of women with migraine notice a relationship between their menstrual cycle and their headaches. For some, their period brings relief; for others, their period acts as a trigger for a migraine. We suspect that all of this is related to the fall in estrogen levels that accompanies menstruation. Women who have headaches before their periods and in whom the period brings relief may not have as dramatic a fluctuation in hormone levels, or their migraines may be triggered by high estrogen levels. As a result, their headaches improve with the premenstrual drop in estrogen.

The same type of variation is seen in migraneurs as they enter menopause -- for some, menopause brings complete relief, while for others, migraines worsen. Because there is such variation, treatment of hormonal migraines is difficult and consists of much trial and error. As I tell my patients, "You are your own experiment." Magnesium supplements help many women, and the use of preventive medications like Cafergot or nonsteroidal anti-inflammatory drugs (aspirin, for example) just before the period can help prevent a migraine.

For menstruating premenopausal women, sometimes birth control pills will help the migraines, but often they make the headaches worse. Low-dose estrogen supplementation beginning a few days before the period will help some women. Sometimes, we induce an artificial, temporary menopause to see if severe migraines are relieved; if so, we add back a little estrogen to see what happens. If migraines occur once the estrogen is returned, these women may benefit from a hysterectomy and removal of the ovaries -- they will not, however, be able to take estrogen replacement therapy. This is an extremely drastic option and should only be undertaken after extensive investigation by a doctor who is well versed in hormonal migraines.

In the end, effective treatment requires close communication between patient and doctor and a willingness to try a variety of therapies until, together, you find one that works.