Approaches to the therapy of hormone-related headaches are reviewed from the Department of Neurology, Temple University School of Medicine and the Comprehensive Headache Center at Germantown Hospital, Philadelphia, PA, and the Reproductive Endocrine Unit, National Institute of Child Health and Human Development, NIH, Bethesda, MD. Migraine can occur before, during, or after menstruation, or at the time of ovulation. During menstruation, it is often associated with dysmenorrhea and before or during menstruation, migraine is frequently refractory to treatment. These are the times of greatest fluctuation in estrogen levels. The primary trigger of menstrual migraine appears to be the withdrawal of estrogen rather than progesterone. Changes in the sustained estrogen levels with pregnancy (increased) and menopause (decreased) can result in changes in headache frequency and intensity. Women who have migraine exclusively with their menses can be treated by the perimenstrual use of prophylactic medication (antidepressants, beta-blockers, calcium channel blockers, or methysergide). The efficacy of pyridoxine and diuretics has not been established in double-blind studies. Ergotamine tartrate at bedtime or twice a day is an effective prophylactic agent. Headache associated with oral contraceptive use or menopausal hormonal replacement therapy may be related in part to periodic discontinuation of estrogens. Oral contraceptives can induce, change, or alleviate headache. They can trigger the first migraine attack, most often in women with a family history of migraine. Stopping the contraceptive may not bring immediate headache relief and there may be a delay of one-half to one year or no improvement. 
COMMENT. The influence of the menstrual cycle on migraine in older children and adolescents requires further evaluation and attention. The first migraine attack may be triggered by oral contraceptives and this possible cause should be considered in adolescent girls with migraine.