Migraine affects approximately one in five women in the UK, compared with one in fifteen men — a disparity driven largely by hormonal fluctuations. According to the Migraine Trust, menstrual migraine (attacks occurring within two days before or three days after the onset of menstruation) affects roughly 50% of women who experience migraine, making it one of the most common and predictable migraine patterns.

Community pharmacists are well placed to help women with menstrual migraine optimise their OTC treatment, understand when prescription options might help, and recognise patterns that warrant medical review. The renewed Women's Health Strategy underscores the importance of addressing women's health conditions proactively across all healthcare settings.

Understanding menstrual migraine

There are two recognised patterns:

Pure menstrual migraine — attacks occur exclusively within the perimenstrual window (day -2 to day +3 of menstruation) and at no other time. This affects approximately 7–10% of women with migraine.

Menstrually related migraine — attacks occur during the perimenstrual window but also at other times of the cycle. This is far more common, affecting around 40% of women with migraine.

The trigger in both cases is the natural fall in oestrogen levels that occurs in the late luteal phase, just before menstruation begins. This withdrawal effect sensitises trigeminal nerve pathways and lowers the migraine threshold.

OTC treatment: timing is everything

For menstrual migraine, the predictable timing of attacks gives pharmacists a valuable counselling advantage — treatment can be pre-emptive rather than reactive.

NSAIDs

Naproxen and ibuprofen are first-line OTC options. The key pharmacist advice: start treatment one to two days before the expected onset of menstruation, rather than waiting for the headache to begin.

• Naproxen 250mg twice daily (available OTC for period pain) — longer-acting, better suited to the multi-day pattern of menstrual migraine
• Ibuprofen 400mg three times daily — effective but shorter duration of action
• Aspirin 900mg as a single dose at onset — an alternative for women who tolerate aspirin

Combination analgesia

Paracetamol 500mg plus aspirin 500mg (with or without caffeine) is an effective combination for acute migraine attacks. Caffeine-containing formulations enhance analgesic absorption and are supported by Cochrane evidence for acute migraine.

Anti-emetics

Many women with menstrual migraine experience significant nausea. OTC domperidone 10mg (available behind the counter in some products) or cyclizine can be recommended alongside analgesia. Pharmacists should advise taking the anti-emetic 20 minutes before the painkiller where possible.

Triptans: when to discuss

Sumatriptan 50mg is available OTC in the UK (since 2006) under certain conditions. It is the only triptan available without prescription. Pharmacists can supply sumatriptan after a structured assessment confirming:

• The patient has a previous medical diagnosis of migraine
• The patient is aged 18–65
• The attack is a typical migraine for that patient
• No contraindications (cardiovascular disease, uncontrolled hypertension, hepatic impairment, concurrent use of ergotamine or other triptans)

For menstrual migraine specifically, sumatriptan can be highly effective when taken early in an attack. Some women find combining a triptan with naproxen more effective than either alone — a strategy supported by NICE guidelines.

When to refer

Pharmacists should recommend a GP review when:

• OTC treatments are insufficient despite optimal timing and dosing
• Attacks are increasing in frequency or severity
• The patient is using acute treatments on more than 10 days per month (risk of medication overuse headache)
• The patient wants to discuss hormonal prevention (continuous combined pill, oestrogen supplementation in the perimenstrual window)
• The migraine pattern has changed — new aura, sudden onset, or neurological symptoms
• The patient is considering pregnancy (migraine management in pregnancy requires specialist input)

Important: combined hormonal contraception (the combined pill, patch or ring) is contraindicated in migraine with aura due to increased stroke risk. Pharmacists dispensing these products should ask about migraine history.

Preventing menstrual migraine

While prevention is a prescriber decision, pharmacists can usefully signpost patients to discuss:

• Perimenstrual NSAID prophylaxis — naproxen 250mg BD starting two days pre-period, continued for seven days, is recommended by NICE for pure menstrual migraine
• Perimenstrual triptan prophylaxis — frovatriptan 2.5mg BD for six days around menstruation (prescription only) has good evidence in pure menstrual migraine
• Continuous combined contraception — eliminating the pill-free interval removes the oestrogen withdrawal trigger (but contraindicated in migraine with aura)
• Magnesium supplementation — 400mg daily from day 15 of the cycle to the end of menstruation has some evidence for reducing menstrual migraine frequency, though quality is low

Keeping a diary

One of the most practical pieces of advice a pharmacist can offer is to recommend a migraine diary. Three months of records showing attack timing, severity, treatments used and menstrual cycle dates give the GP or neurologist the data needed to confirm the menstrual pattern and choose the right preventive strategy.

The Migraine Trust and National Migraine Centre offer free downloadable diary templates.

Pharmacy as the first conversation

PharmSee data shows over 13,000 community pharmacies across England, each one a potential starting point for the conversation that helps a woman move from "I just get bad headaches around my period" to an effective, targeted treatment plan. With 1,742 active pharmacy vacancies reflecting ongoing workforce demand, these conversations happen thousands of times a day across the country.

Sources

• NICE Clinical Knowledge Summary: Migraine (2023 update)
• Migraine Trust: menstrual migraine patient information
• MacGregor EA, Migraine in women. Continuum 2021
• Cochrane Review: Sumatriptan for acute migraine attacks (2014)
• Department of Health and Social Care, Women's Health Strategy renewal (April 2026)
• PharmSee pharmacy and vacancy data, accessed April 2026

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