Menstrual Migraine

Menstrual Migraine Management

Menstrual Migraine Strategies:

Limiting the difference in estrogen content between the active pills and placebo to ≤10 μg of ethynyl estradiol (EE) helps prevent menstrual migraine. 

CHC regimens with declines of ≤10 μg EE include the following options:

(1)  Monophasic

Examples include 

  • Lo Loestrin Fe®: 2 day pill-free interval monthly with 10 mg EE drop- norethindrone/ethynyl estradiol 1mg/10mcg days x24 days, then norethindrone/ethynyl estradiol 0mg/10mcg x2 days, then ferrous fumarate 75mg x2 days
  • Amethyst®: no decline, continuous active 20mg EE pills- levonorgestrel/ethynyl estradiol 0.9mg/20mcg x28 tab


(2)  Monophasic Extended Dose Packs: 91-day extended cycle pack with 10 mg EE decline in week 13. Several brands of this combination dosing are available on the market.

  • Levonorgestrel/ethynyl estradiol 0.1mg/20mcg x84 days, then 0mg/10mcg for 7 days


(3)  Quadriphasic

Examples include

  • Natazia®: 3 successive drops in estradiol valerate (EV), each about 6.5ug EE decline- estradiol valerate/dienogest 3mg/0mg x2 days, then 2mg/2mg x5 days, then 2mg/3mg x17 days, then 1mg/0mg x2 days, then inert tab x2 days


(4)  Can also use the following combination which limits estrogen drop to ≤10 μg EE: 

  • Norethindrone/ethynyl estradiol 1mg/20mcg x24 days then ferrous fumarate x4 days at bedtime AND Premarin (conjugated estrogens) 1.25mg at bedtime days 25-28 
  • There are many brands of this Norethindrone/ethynyl estradiol formulation available; we find that one commonly used one is Junel Fe 24® but please use your preferred CHC with similar dosing