Menstrual migraine is migraine that falls in a fixed window: from two days before your period to three days into it. Not somewhere in that week, but inside that five day window. And not once, but in at least two out of every three cycles.
That precision is not pedantry. It is the whole difference between a hunch and a pattern your GP can use.
In a Dutch cohort of 563 women with migraine, the chance of an attack in that perimenstrual window was over one and a half times higher than across the rest of the cycle (Cephalalgia, 2026). That is not a subtle effect.
Why does menstrual migraine feel heavier?
Because on average the attacks are heavier. Attacks around menstruation last longer, come with nausea more often, and respond less well to the usual acute treatment than attacks at other points in your cycle. That is a consistent finding, not personal bad luck.
Many women assume they simply cope worse with these attacks. That is not what is happening.
The trigger is the rapid fall in your oestrogen at the end of your cycle. A 2023 critical review does conclude that the evidence for that explanation is thinner than usually suggested: small groups and inconsistent definitions (PMID 37730536). The pattern holds; the mechanism is still moving.
What you can do with that: if your heavy months keep landing on the same cycle days, it is not chance and not something to talk around.
Pure or menstrually related migraine?
It depends on what happens outside that window. If you only get attacks around your period and none across the rest of the cycle, that is called pure menstrual migraine. If you get them around your period and at other moments as well, it is menstrually related migraine. That second group is by far the larger one.
| Pure menstrual migraine | Menstrually related migraine | |
|---|---|---|
| When attacks arrive | Only from 2 days before to 3 days after your period starts | In that window, and at other points in your cycle |
| How often it must hold | In at least 2 of 3 cycles | In at least 2 of 3 cycles, plus attacks outside it |
| How common it is | The smaller group | Most women with a menstrual pattern |
| What your diary must capture | Mainly the cycle day per attack | The cycle day and the attacks outside the window |
Why this matters: for the second group, "I get migraine around my period" tells only half the story. You need the other attacks too, to see whether the window genuinely stands out. Without that second half, almost any migraine looks hormonal.
Take two women with the same 28 day cycle, both with "hormonal migraine" saved in their app. The first has attacks only on days 27, 28 and 1, three cycles running, and nothing else. The second has those too, plus one on day 14 and sometimes on day 9.
Same app label, two different stories. For the first, the attack sits tight in the window; for the second, the window is only part of the picture. For your GP, that distinction is half the appointment.
Can you have menstrual migraine if you get aura?
Yes, and that surprises many people. Menstrual migraine is often presented as something that happens to women without aura. In a Dutch diary study of 526 women it occurred about equally often in both groups: 59% in women without aura and 53% in women with aura (PMID 37259230).
What does stand out: the attacks arriving around menstruation usually run without aura, in both groups.
So you can know aura from your mid cycle attacks and have none of it around your period. That is why you note aura per attack, rather than as a property of yourself.
The distinction is more than trivia. For migraine with aura, Dutch headache guidance gives particular attention to combined pill use, because of a raised risk of stroke. Do you use hormonal contraception and sometimes see shimmering? Name it with your GP. What contraception does to your hormones more broadly is in the pill and side effects.
Is it migraine or severe PMS?
Those two overlap in timing, not in symptom. PMS plays mainly in the days before your period and covers a broad package: mood, breast tenderness, bloating, irritability. Migraine is an attack of severe, often one sided head pain that takes you out.
They can sit alongside each other perfectly well. In the same woman, in the same week.
The practical difference is what you can read from each. With PMS you look at the whole set of symptoms; with migraine you look at attacks with a start and an end. More on that first category is in PMS symptoms.
Which blood test belongs here?
No blood test establishes menstrual migraine. The diagnosis comes from your pattern, not from a vial. What blood testing does do is check whether something else is playing along that worsens the attacks or resembles them.
With a fixed monthly pattern, that is mostly the iron side.
What strikes me here: women with a tight menstrual pattern have often tracked their cycle for months, but never their iron. Yet those are the two that land in the same week.
If you lose a lot of blood, your ferritin drops across the months with it. With menstrual migraine that is a double hit: the same week that triggers the attack also costs you iron. How that link runs is in headache from iron deficiency, and heavy bleeding itself is covered in heavy periods.
If you want your hormonal picture and your iron looked at together, hormones for women fits that. Always discuss a value outside the range with your GP: what it means for you depends on your symptoms, your age and your cycle.
What do you record over the next three cycles?
Four things per headache day: the cycle day counted from the first day of your period, how long the attack lasted, whether nausea or light and sound sensitivity came with it, and whether you saw shimmering beforehand.
Three cycles, because after two you still cannot tell whether it is chance.
If I could get one thing across in this whole piece, it is this: write down the cycle day, not just "around my period". That single number does more work than any adjective.
After that you can see for yourself which of the two columns above you fall into. That is exactly the information your GP can work with, and it saves you the feeling of having to defend yourself. The broader explanation of your cycle and headache is in hormonal headache. If your cycle is already changing, read migraine in menopause.
References
- Verhagen IE, van der Arend BWH, van Casteren DS, et al. Migraine with and without aura in relation to the menstrual cycle and other hormonal milestones: a prospective cohort study. Cephalalgia. 2023;43(6). PMID 37259230.
- van der Arend BWH, Bakker S, van Casteren DS, et al. Migraine attack incidence in relation to the post-ovulatory estrogen decline: a prospective cohort study. Cephalalgia. 2026. doi:10.1177/03331024261436415.
- Raffaelli B, Do TP, Chaudhry BA, Ashina M, Amin FM, Ashina H. Menstrual migraine is caused by estrogen withdrawal: revisiting the evidence. J Headache Pain. 2023;24(1):131. PMID 37730536.
- Richtlijnendatabase. Sex hormones and migraine, headache guideline. Available via richtlijnendatabase.nl.
- Thuisarts. Migraine. Available via thuisarts.nl.
- RIVM and VZinfo. Migraine: figures and context. Available via vzinfo.nl.
Every blood test result at Lunara includes a professional assessment by a BIG-registered doctor. For treatment decisions, discuss your results with your GP.
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