Menstrual Migraine Diagnostic Criteria Deemed Inadequate

Characteristics of menstrual migraine (MM) differ significantly from non-MM, suggesting updated diagnostic criteria are necessary, according to a case-control study published in JAMA Network Open.

Migraine is a leading cause of lifestyle disability, affecting women more often than men. Approximately 18% to 25% of women who experience migraines report that they are related to menstruation. However, menstrual migraine diagnostic criteria are inadequate, compared with non-MM. Therefore, researchers aimed to compare characteristics of MM vs non-MM and outline new diagnostic criteria to differentiate. 

The researchers reviewed patients from the Danish Migraine Population Cohort. Study participants completed a 105-item migraine questionnaire which included a 12-item physical health component scale (PCS-12), 12-item self-perceived mental health scale (MCS-12), and rating of migraine intensity using a visual analog scale (VAS) for pain. Questions related to pharmacological treatment outcomes were also included. menstrual migraine was diagnosed according to the International Classification of Headache Disorders, Third Edition (ICHD-3). Descriptive statistics and logistic regression analysis were used to examine clinical features of MM. 

A total of 5748 women with migraine who answered the questions related to menstruation were included in the study cohort. Menstrual migraine was present among 16.6% (1532 women). Among the women with MM, 26.8% were classified as having pure MM, 67.7% as menstrually related MM, and 9.9% as having rare pure MM. Women with MM had lower PCS-12 scores than those in the non-MM group (P <.001).

Women in the menstrual migraine group were more likely to experience migraine attacks (odds ratio [OR], 7.21; P <.001), have longer attack duration (OR, 2.32; P <.001), and report higher VAS pain intensity scores (mean score, 7.87 vs 7.43; P <.001) than those with non-MM. Migraine-associated symptoms including nausea, vomiting, and visual disturbances were more frequent in the MM vs non-MM group (all P <.001)

Women with menstrual migraine were more likely to report positive outcomes following treatment with triptans than those with non-MM (82.4% vs 71.8%), suggesting overall greater treatment response.

When comparing clinical characteristics among women with hormonal contraceptive-related MM vs spontaneous MM, greater prevalence of migraine without aura among the hormonal MM group was the only difference.  

Researchers propose the following criteria updates to prevent diagnostic misclassification of patients with MM:

1. Women with rare pure MM are to be included in the diagnostic criteria of pure MM.
2. Chronic migraine and high-frequency episodic migraine are to be excluded from MM diagnostic criteria.
3. Migraine attacks must occur within the time frame of menstruation (days -2 to +3 of the menstruation cycle).
4. Diagnostic criteria should allow inclusion of women having more than one migraine attack during the menstrual cycle.  

This study was limited by potential bias due to self-reported data. Additionally, proposed diagnostic criteria were supported by logic and population-based information, not biological data. Finally, data on migraine recurrence, onset, and termination were lacking. 

Researchers concluded, “Menstrual migraine is an important diagnostic entity, and these findings suggest that new diagnostic criteria are necessary.”