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Symptoms of Premenstrual Syndrome in Female Migraineurs with and Without Menstrual Migraine Kjersti Grøtta Vetvik1,2* , E

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Symptoms of Premenstrual Syndrome in Female Migraineurs with and Without Menstrual Migraine Kjersti Grøtta Vetvik1,2* , E Vetvik et al. The Journal of Headache and Pain (2018) 19:97 The Journal of Headache https://doi.org/10.1186/s10194-018-0931-6 and Pain SHORT REPORT Open Access Symptoms of premenstrual syndrome in female migraineurs with and without menstrual migraine Kjersti Grøtta Vetvik1,2* , E. Anne MacGregor3,4, Christofer Lundqvist1,2,5,6 and Michael Bjørn Russell1,6 Abstract Background: Menstrual migraine (MM) and premenstrual syndrome (PMS) are two conditions linked to specific phases of the menstrual cycle. The exact pathophysiological mechanisms are not fully understood, but both conditions are hypothesized to be triggered by female sex hormones. Co-occurrence of MM and PMS is controversial. The objective of this population-based study was to compare self-assessed symptoms of PMS in female migraineurs with and without MM. A total of 237 women from the general population who self-reported migraine in at least50% of their menstruations in a screening questionnaire were invited to a clinical interview and diagnosed by a neurologist according to the International Classification of Headache Disorders II (ICHD II), including the appendix criteria for MM. All women were asked to complete a self-administered form containing 11 questions about PMS-symptoms adapted from the Diagnostic and Statistical Manual of Mental Disorders. The number of PMS symptoms was compared among migraineurs with and without MM. In addition, each participant completed the Headache Impact test (HIT-6) and Migraine Disability Assessment Score (MIDAS). Findings: A total of 193 women returned a complete PMS questionnaire, of which 67 women were excluded from the analyses due to current use of hormonal contraception (n = 61) or because they did not fulfil the ICHD-criteria for migraine (n = 6). Among the remaining 126 migraineurs, 78 had MM and 48 non-menstrually related migraine. PMS symptoms were equally frequent in migraineurs with and without MM (5.4 vs. 5.9, p = 0.84). Women with MM reported more migraine days/month, longer lasting migraine attacks and higher HIT-6 scores than those without MM, but MIDAS scores were similar. Conclusion: We did not find any difference in number of self-reported PMS-symptoms between migraineurs with and without MM. Keywords: Migraine, Menstrual migraine, Premenstrual syndrome, Hormones, Menstruation, Menstrual cycle Introduction incidence of migraine attacks varies across the menstrual Migraine is two to three times more prevalent in women cycle, peaking on 5 days centering on the first day of compared to men during reproductive age [1, 2]. This menstruation [3]. In a subset of female migraineurs, mi- female preponderance is hypothesized to result from the graine attacks occur regularly and predominantly in this influence of female sex hormones on neurotransmitter perimenstrual phase. The International Classification of systems and neuropeptide release involved in migraine Headache Disorders 3rd edition (ICHD 3) defines men- pathophysiology, neuronal excitability, and underlying strual migraine (MM) as migraine attacks occurring on genetic and environmental factors [1]. In women, the day − 2 to + 3 of the menstrual cycle in at least two out of three consecutive menstrual cycles [4]. Previous editions of * Correspondence: [email protected] the classification, i.e. ICHD 2 and ICHD 3 beta, restricted 1Head and Neck Research Group, Research Centre, Akershus University MM to include only migraine without aura, but the ICHD hospital, Lørenskog, Norway 3 provides alternative criteria for MM with aura [4–6]. 2Department of Neurology, Akershus University Hospital, 1478 Lørenskog, Norway MM with and without aura are further subdivided into Full list of author information is available at the end of the article pure menstrual migraine (PMM) and menstrually-related © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. Vetvik et al. The Journal of Headache and Pain (2018) 19:97 Page 2 of 7 migraine (MRM). Women with PMM have migraine at- as questions about PMS. The 11 PMS-questions consisted tacks occurring exclusively at menstruation, while women of a blinded forward-backward translation to Norwe- with MRM have additional non-menstrual attacks. For gian of the research criteria for premenstrual dys- research purposes, a prospective headache diary for at phoric syndrome (PMDD) from the Diagnostic and least three consecutive menstrual cycles is recommended StatisticalManualofMentalDisorders4thEdition to confirm the diagnosis. More than 50% of female migrai- (DSM IV) (with the possible answers yes/no [20]. neurs report an association between migraine and men- Headaches were classified according to the International struation, but the prevalence of MM is only about 20% Classification of Headache Disorders 2nd edition (ICHD 2) among female migraineurs when the diagnostic criteria including the appendix criteria for MM without aura [6]. are used [7, 8]. Women with migraine, who did not fulfil these criteria, Premenstrual syndrome (PMS) is another disorder dir- were classified as non-menstrual migraineurs (nMM). No ectly linked to a specific phase of the menstrual cycle. It prospective diaries were used to confirm the diagnoses. presents with a wide variety of physiological and psycho- Women were excluded from analyzes if they were cur- logical symptoms occurring in the luteal phase which re- rently using hormonal contraception or were not diagnosed solve during or shortly after onset of menstruation [9–11]. with migraine by the neurologist. A symptom-free interval between the end of menstruation and the time of ovulation is required in order to exclude Statistics other disorders [10]. The diagnosis can only be made in The data were analyzed using SPSS version 22. χ2-tests and presence of ovulation, thus excluding women using most Students t-tests were used to compare categorical and con- types of hormonal contraception. Different diagnostic cri- tinuous data. A p-level below 0.05 was considered signifi- teria for PMS exist, but a common feature is the require- cant, with the exception of one analysis with multiple tests ment that symptoms must cause significant impairment (comparison of 11 specific items of the PMS-questionnaire) and interfere with daily functioning [9]. The diagnosis for which a Bonferroni-correction was performed and the should additionally be confirmed by a symptom diary kept level of significance was reduced to 0.0045 (0.05/11). over at least two cycles [11]. Although up to 80% of all women report mild symptoms of PMS, only about one Findings fourth fulfill diagnostic criteria for PMS [12, 13]. The response rate for the questionnaire was 73%. Of 360 To date, few studies have looked at a possible relation- women reporting migraine in ≥1/2 of their menstrua- ship between PMS and MM and the available studies pro- tions, 52 were not eligible due to insufficient Norwegian vide diverging results [14–17]. A link between PMS and language skills (n = 9), emigration (n = 4) and no reply to MM is therefore controversial [18, 19]. The aim of the at least five phone calls (n = 39). Among the eligible, present study was to explore the association between MM 77% (237) participated in the interview (Fig. 1). and PMS by comparing self-reported PMS-symptoms in Of the 237 women who were interviewed, 193 (81.4%) female migraineurs from the general population with and returned a complete PMS-questionnaire. Another 67 without MM without aura. women were excluded from the analyses due to current use of hormonal contraception (n = 61) or because they Methods did not fulfill the ICHD-criteria for migraine by inter- The current paper presents results from an epidemio- view (n = 6). Among the remaining 126 women, 78 had logical study on MM from the general population and MM (of which six had PMM) and 48 had nMM (Fig. 1). the method has been described elsewhere [7]. In January Women with MM reported a significantly higher number 2005, a random sample of 5000 women aged 30–34 years of migraine days/month, longer duration of attacks and a from the general population received a mailed screen- higher HIT-6 score than did women without MM (Table 1). ing questionnaire about migraine and the relationship Of the eight women with MM who used migraine prophy- of attacks to menstruation. In 2011/2012, women with laxis, four used beta blockers, two candesartan, one onabo- self-reported migraine in at least 50% of their men- tolinum toxin A, and one topiramate. In the nMM group, struations and < 180 headache days during the preced- one woman was using onabotolinum toxin A. ing year were invited to a semi-structured interview The mean number of reported PMS-symptoms conducted by a neurologist. The interview focused on among all women was 5.6 (±2.9) out of 11, with no headache and migraine, migraine treatment, menstrual difference between women with and without MM (5.4 symptoms, and use of hormonal contraception. vs 5.9, p = 0.84).The individual responses to the spe- Each participant was also asked to complete a self-admin- cific PMS-items are shown in Table 2.Womenwith istered questionnaire includingdemographicdata,theim- nMM reported more premenstrual affective symptoms pact of headache/migraine (Headache Impact test, HIT-6 (question 1–2), but after correction for multiple test- and Migraine Disability Assessment Scale, MIDAS), as well ing, the differences were not statistically significant. Vetvik et al. The Journal of Headache and Pain (2018) 19:97 Page 3 of 7 Fig. 1 Flow chart of the study Discussion to retrospective self-reporting, the lack of information In this study, women with MM did not report more about the severity of the different symptoms, and whether PMS symptoms than did women with nMM.
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