Non-migraine headache across the menstrual cycle in women with and without premenstrual syndrome

Should migraine without aura be further divided? A study of 1444 female patients with migraine without aura

To explore the possibility of further dividing migraine without aura (MWA), 1444 female patients fulfilled the criterion were recruited, and grouped basing on the association of MWA onset with menarche and childbirth (group J1, onset before menarche; group J2, onset between menarche and childbirth; group J3, onset after childbirth). By comparing migraine (side, location, aggravated by routine physical activity, NRS score, frequency, accompanying symptoms, with premonitory symptom (PS) and trigger, sum of PS and trigger) and migraine-related factors [chronic daily headache, medicine overused headache, body mass index (BMI), education level, exercise status, sleep status, consumption of tea/coffee/alcohol, patient health questionnaire-9 (PHQ-9) score and generalized anxiety disorder-7, (GAD-7) score)] among groups, it was found that the J1 group and the J2 group presented more typical migraine features than the J3 group; 2) the J3 group was more prone to emotion and sleep disorders, weight management issues, frequent migraine attacks and medication overuse. This study provided a basis for further dividing MWA. Genetic research should be conducted and treatment should be prescribed accordingly because the underlying pathogenesis may be different.

Menstrual Cycle and Headache in Teenagers

OBJECTIVE

This population-based study on school-aged girls aimed to estimate the rate of peri-menstrual headache, evaluate headache pain pattern during the menstrual cycle, and verify its relationships with physical, psychosocial and life-style factors.

METHODS

The students (n = 4973) fulfilled a self-administered questionnaire on demographic and behavioral characteristics, menarche, menstrual pattern and features including headache and dysmenorrhea. The prevalence of headache and the mean pain intensity score at the three menstrual cycle phases (premenstrual, menstrual, in-between period) were estimated, both overall and by gynecological year. Furthermore, the prevalence of three different patterns of headache (peri menstrual/mid-cycle/acyclic) was evaluated, together with the mean pain intensity score.

RESULTS

The overall prevalence of headache at least once at any time during the menstrual cycle was 64.4%. At multivariable logistic analysis, gynecological age (OR 1.07; 95%CI 1.03-1.12), middle social level (1.24; 1.01-1.55, compared to high social level), physical activity (0.67; 0.51-0.89), oral contraceptive use (1.34; 1.04-1.73) and dysmenorrhea (2.30; 1.54-3.42) were significantly associated with headache. Among girls with headache, 83.4% had peri-menstrual headache (44.6% premenstrual, 38.8% menstrual), 3.5% mid-cycle headache and 13.2% acyclic headache. The gynaecological age and dysmenorrhea were significantly associated with the headache pattern (p = 0.03 and p < 0.0001, respectively).

CONCLUSIONS

This study suggests that peri-menstrual headache is highly prevalent among adolescents. In girls, the headache rate linearly raises with higher gynecological age; menses-related painful syndromes, such as headache and dysmenorrhea, are strongly interrelated. The anamnesis and monitoring of menstrual health should be mandatory when taking care of girls with headache.

Endogenous inhibition of pain and spinal nociception in women with premenstrual dysphoric disorder

Purpose

Premenstrual dysphoric disorder (PMDD) is characterized by severe affective and physical symptoms, such as increased pain, during the late-luteal phase of the menstrual cycle. The mechanisms underlying hyperalgesia in women with PMDD have yet to be identified, and supraspinal pain modulation has yet to be examined in this population. The present study assessed endogenous pain inhibitory processing by examining conditioned pain modulation (CPM, a painful conditioning stimulus inhibiting pain evoked by a test stimulus at a distal body site) of pain and the nociceptive flexion reflex (NFR, a spinally-mediated withdrawal reflex) during the mid-follicular, ovulatory, and late-luteal phases of the menstrual cycle.

Methods

Participants were regularly-cycling women (14 without PMDD; 14 with PMDD). CPM was assessed by delivering electrocutaneous test stimuli to the sural nerve before, during, and after a painful conditioning ischemia task. Participants rated their pain to electrocutaneous stimuli, and NFR magnitudes were measured. A linear mixed model analysis was used to assess the influence of group and menstrual phase on CPM.

Results

Compared with controls, women with PMDD experienced greater pain during the late-luteal phase and enhanced spinal nociception during the ovulation phase, both of which were independent of CPM. Both groups showed CPM inhibition of pain that did not differ by menstrual phase. Only women with PMDD evidenced CPM inhibition of NFR.

Conclusion

Endogenous modulation of pain and spinal nociception is not disrupted in women with PMDD. Additionally, greater NFR magnitudes during ovulation in PMDD may be due to tonically-engaged descending mechanisms that facilitate spinal nociception, leading to enhanced pain during the premenstrual phase.

Beta-adrenergic receptor mechanisms and pain sensitivity in women with menstrually related mood disorders

Somatic symptoms experienced by women with a menstrually related mood disorder (MRMD) during their premenstrual luteal phase contribute to functional impairment. Yet, investigations on pathophysiological mechanisms contributing to heightened pain sensitivity in MRMD are sparse. During the luteal phase, 61 women with an MRMD and 61 non-MRMD controls were evaluated for β-adrenergic receptor (β-AR) responsivity using the isoproterenol sensitivity test. A subset (43 MRMD and 50 non-MRMD) then entered a double-blind, placebo-controlled, crossover protocol to examine the effect of β-AR blockade with intravenous propranolol on sensitivity to experimental (cold pressor and ischemic) and clinical (McGill Pain Questionnaire score) pain. Women with an MRMD exhibited greater β1- and β2-AR responsivity, ischemic pain intensity, and affective clinical pain ratings than controls. Propranolol increased cold pressor pain tolerance in both groups, but it decreased cold pain intensity and ischemic pain unpleasantness ratings only in non-MRMD women. In contrast, propranolol decreased affective ratings of clinical pain in women with MRMD. Exploratory analyses indicated that only in MRMD women did greater β-AR responsivity predict greater sensitivity to cold pressor and ischemic pain. This study provides the first evidence for a role of β-AR mechanisms in the hyperalgesia and clinical pain experienced by women with MRMDs.

PERSPECTIVE

This article describes the effects of β-adrenergic receptor stimulation and blockade on experimental and clinical pain sensitivity in women with an MRMD. The results of this study may have implications for the management of the substantial somatic premenstrual symptomatology experienced by women with an MRMD.

Mid-cycle headaches and their relationship to different patterns of premenstrual stress symptoms

BACKGROUND

Recent research has shown that affective changes associated with the menstrual cycle may follow diverse patterns, including a classic premenstrual syndrome pattern, as well as the mirror opposite pattern, referred to as a mid-cycle pattern.

OBJECTIVE

Test for the presence of a mid-cycle pattern of headaches, in addition to a menstrual pattern and a noncyclic pattern; test for an association between experiencing a specific pattern of headaches and a specific (previously identified) pattern of depression/anxiety; and test for mean-level differences, across headache pattern groups, in average headache index and depression/anxiety scores (averaged across 2 menstrual cycles for each participant).

METHODS

A sample of 213 female university students completed daily questionnaires regarding symptoms of headaches and depression/anxiety for 2 menstrual cycles. Hierarchical linear modeling, polynomial multiple regression, analyses of variance, and chi-square analyses were used to test the hypotheses.

RESULTS

Confirmed the existence of a mid-cycle pattern of headaches (16%), in addition to a menstrual pattern (51%), and a noncyclic pattern of headaches (33%). Patterns of headaches and affective change were significantly associated (χ(2) = 21.33, P = .0003; 54% correspondence), as were the average headache index and depression/anxiety scores (r = .49; P < .0001). No significant mean-level differences were found between the headache pattern groups on the average headache index scores or depression/anxiety scores.

CONCLUSIONS

A significant number of women experience a mid-cycle pattern of headaches during the menstrual cycle. Moreover, women often, but not always, demonstrate the same pattern of headaches and depression/anxiety symptoms.

Sex, gender, and pain: a review of recent clinical and experimental findings

Sex-related influences on pain and analgesia have become a topic of tremendous scientific and clinical interest, especially in the last 10 to 15 years. Members of our research group published reviews of this literature more than a decade ago, and the intervening time period has witnessed robust growth in research regarding sex, gender, and pain. Therefore, it seems timely to revisit this literature. Abundant evidence from recent epidemiologic studies clearly demonstrates that women are at substantially greater risk for many clinical pain conditions, and there is some suggestion that postoperative and procedural pain may be more severe among women than men. Consistent with our previous reviews, current human findings regarding sex differences in experimental pain indicate greater pain sensitivity among females compared with males for most pain modalities, including more recently implemented clinically relevant pain models such as temporal summation of pain and intramuscular injection of algesic substances. The evidence regarding sex differences in laboratory measures of endogenous pain modulation is mixed, as are findings from studies using functional brain imaging to ascertain sex differences in pain-related cerebral activation. Also inconsistent are findings regarding sex differences in responses to pharmacologic and non-pharmacologic pain treatments. The article concludes with a discussion of potential biopsychosocial mechanisms that may underlie sex differences in pain, and considerations for future research are discussed.

PERSPECTIVE

This article reviews the recent literature regarding sex, gender, and pain. The growing body of evidence that has accumulated in the past 10 to 15 years continues to indicate substantial sex differences in clinical and experimental pain responses, and some evidence suggests that pain treatment responses may differ for women versus men.

Evaluation of an electronic diary as a diagnostic tool to study headache and premenstrual symptoms in migraineurs

OBJECTIVE

To evaluate an electronic diary as a tool to evaluate the occurrence and relationship of headaches and premenstrual syndrome (PMS) symptoms throughout the menstrual cycle in women with migraine.

BACKGROUND

Menstrually related headache and PMS significantly impact the quality of life of many women. The time relationship of these 2 menstrually related problems is not well understood and not well described.

METHODS

Twenty women with migraine experiencing regular menstrual cycles were enrolled in a prospective study designed to date- and time-stamp data, both self- and computer-prompted, headache and PMS symptoms, for 3 consecutive months. A previously validated PMS score was calculated by grading 23 PMS criteria on a scale of 0 to 3 (0 = no symptoms, 3 = severe symptoms).

RESULTS

The total number of data entries recorded was 2009, composed of 56 menstrual cycles in 20 migraineurs. Five hundred forty-four entries reported a current, prodromal, or previous headache. The mean daily occurrence of headache increased beginning on cycle day -5, peaked on days +1 to +5, and returned to baseline by day +7. Mean daily PMS scores ranged from 2.4 to 12. Mean daily PMS scores peaked on days -6 to +2 and returned to baseline by day +8.

CONCLUSIONS

An electronic diary may have potential as a diagnostic tool in studying headaches and PMS symptoms throughout the menstrual cycle. The occurrence of headache and PMS symptoms in migraineurs follows similar time courses.

Menstrual tension-type headache: evidence for its existence

OBJECTIVE

To determine whether menstrual tension-type headache is a real disorder.

BACKGROUND

An appendix was included in the second edition of the International Classification of Headache Disorders by the International Headache Society. Diagnostic criteria are proposed in this appendix for 2 types of menstrual migraine: pure menstrual migraine without aura and menstrually related migraine without aura. References to menstrual tension-type headache do not appear in this classification.

METHODS

In a neurological outpatient clinic 165 patients were identified in whom headache was related to menstruation and the criteria of the International Classification of Headache Disorders for menstrual migraine adapted to menstrual tension-type headache were applied.

RESULTS

Twenty-one patients met the criteria of menstrual tension-type headache, 6 for pure menstrual tension-type headache, and 15 for menstrually related tension-type headache.

CONCLUSION

Menstrual tension-type headache is a real condition that should be recognized in the International Classification of Headache Disorders.

Overview of orofacial pain: epidemiology and gender differences in orofacial pain

Chronic orofacial pain is a prevalent problem that encompasses numerous disorders with diverse causes and presenting symptoms. Compared with men, women of reproductive age seek treatment for orofacial pain conditions, as well as other chronic pain disorders more frequently. Important issues have been raised regarding gender and sex differences in genetic, neurophysiologic, and psychosocial aspects of pain sensitivity and analgesia. Efforts to improve our understanding of qualitative sex differences in pain modulation signify a promising step toward developing more tailored approaches to pain management.

Hormone-related headache: pathophysiology and treatment

Epidemiological data suggest a link between migraine and the female sex hormones. Indeed, it is known that estrogen affects various brain functions, including pain perception. The prevalence of migraine is similar in boys and girls before puberty, but is 3-fold higher in postpubertal females compared with males. Migraine attacks in women are more likely to occur in the perimenstrual period and occur exclusively so in some women. The acute treatment of menstrual migraine is similar to that of non-menstrually related attacks, but the response to treatment may be less favourable. Perimenstrual prophylaxis, with NSAIDs, triptans or estradiol, is effective in decreasing attack frequency and severity. The use of oral contraceptives (OCs) may change migraine frequency and severity. Since both migraine and hormonal contraceptive use are risk factors for ischaemic stroke, the use of OCs in women who experience migraine should be made only after consideration of the benefit-risk ratio. Migraine typically, but not invariably, improves during the last two trimesters of pregnancy, and may worsen in the postpartum period. When using drugs to treat migraine during pregnancy, potential risks to the mother and fetus should be considered. The prevalence of migraine decreases with advancing age and it improves in many, but not all, women after the menopause. However, in the perimenopausal period, migraine may worsen as a result of fluctuations in estrogen levels. Reducing the estrogen dose and changing the estrogen type or the route of administration of hormone replacement therapy (HRT) from oral to transdermal may reduce headache. Migraine is not a risk factor for stroke in postmenopausal women. When considering symptomatic HRT for postmenopausal migraneurs, the usual indications and contraindications should be applied. HRT may also exacerbate migraine.

Water deprivation: a new migraine precipitant

Fifty migraineurs were asked if insufficient fluid intake could provoke their migraine attacks. Twenty replied "yes," 7 were doubtfully positive, and 23 said "no." In addition 14 of 45 migraineurs at a meeting of the British Migraine association (UK) also recognized fluid deprivation as one of their migraine triggers. Thus a total of 34 of 95 migraineurs knew that dehydration could provoke their attacks, a precipitant not recognized by the medical profession. This indicates that we can add fluid deprivation to our list of migraine precipitants. It would be interesting to know the extent to which it applies in other climates. Further research is needed into the mechanism of this precipitant.

Disability Associated With Headaches Occurring Inside and Outside the Menstrual Period in Those With Migraine: A General Practice Study

OBJECTIVES

This study investigated the disability of females who have migraine and other headache attacks occurring during and outside the menstrual period.

METHODS

One thousand four hundred and thirty-four of 3470 female patients (41.3%) aged 14 to 50 years registered at a UK general practice completed two questionnaires. The first questionnaire assessed the prevalence of headache, depression, and bodily pain in the total population. The second questionnaire assessed the disability of all headaches over a 2-month period (to capture a complete menstrual cycle) for patients reporting migraine who were still menstruating. Disability was assessed as the time lost and time spent at less than 50% productivity in normal activities due to headache, and analyzed as rank sums using the Mann-Whitney U-test.

RESULTS

The first part of the study showed that the prevalence of headache (66.1%), depression (55.4%), and bodily pain (40.6%) were high in this population of women. Thirty migraine patients who were still menstruating reported 89 migraine and 114 nonmigraine headache episodes in the second part of the study. For migraine, the rank order of time at less than 50% productivity was greater for attacks taking place inside the menstrual period than for those occurring outside the menstrual period. The comparison was significant for time at less than 50% productivity (P=.01). For nonmigraine headaches, the rank order of time lost was greater for attacks taking place outside the menstrual period than for those occurring inside the menstrual period. The comparison was not significant for time lost (P= .06).

CONCLUSIONS

For those with migraine, migraine attacks that took place during the menstrual period tended to be slightly more disabling than those taking place outside the menstrual period, but the opposite was true for nonmigraine headache.

Cefaléia menstrual: estudo semiológico de 100 casos

Ao redor de 60% das mulheres com migrânea associam o período menstrual com a desencadear das crises. Para cefaléias não migranosas, essa relação é menos evidente. O objetivo desse estudo é apresentar a caracterização clínica da cefaléia menstrual. Cefaléia menstrual foi conceituada, em nosso estudo, como aquela cefaléia compreendida entre dois dias antes do primeiro dia da menstruação e o último dia da mesma. As variáveis avaliadas foram: intensidade, características e localização da dor e dos sintomas associados. Foi analisada a cefaléia de 100 mulheres (154 períodos menstruais), com idades entre 20 e 45 anos. A maior parte foi classificada como migrânea sem aura; a intensidade era severa no primeiro dia de dor, com redução gradativa nos dias subseqüentes; as cefaléias eram predominantemente de qualidade latejante, referidas como unilaterais em algum momento do ciclo menstrual; a duração foi maior que a tradicionalmente referida na literatura. A maior parte se iniciou dois dias antes do início do ciclo menstrual. Náuseas e/ou vômitos foram os sintomas associados mais freqüentes. Foram diagnosticados 9 casos de cefaléia do tipo tensional, 2 casos de cefaléia cervicogênica e 1 caso de cefaléia em pontadas.

The association of hormone replacement therapy with experimental pain responses in postmenopausal women

Considerable experimental research suggests that ovarian hormones can influence pain perception, and recent epidemiologic and clinical research suggests that exogenous hormone use may influence the prevalence and severity of clinical pain among women. However, to date no studies have examined the influence of hormone replacement therapy (HRT) on experimental pain responses and recent pain complaints among postmenopausal women. In this study, self-reported recent pain and general health were obtained, and thermal pain responses were assessed in three groups of healthy older adults: (1) women on HRT, (2) women not on HRT (No-HRT), and (3) men. Results indicated no group differences in recent pain complaints or self-reported health, but differences emerged for measures of thermal pain perception. Specifically, HRT women showed lower pain thresholds and tolerances than No-HRT women and men, and the latter two groups did not differ from each other. The potential explanations and limitations of the observed findings are discussed.

Sex steroid hormones exert biphasic effects on cytosolic magnesium ions in cerebral vascular smooth muscle cells: possible relationships to migraine frequency in premenstrual syndromes and stroke incidence

Clinically, it is known that: (1) magnesium (Mg) supplementation relieves premenstrual problems (e.g., migraine, bloating and edema) occurring in the late luteal phase of the menstrual cycle; and (2) migraine syndromes, particularly in women, are associated with deficits in brain and serum ionized Mg levels. We investigated whether concentrations of sex steroid hormones, found in the serum during the menstrual cycle of women, are associated with changes in the levels of cytosolic free magnesium ions ([Mg2+]i in single cultured canine cerebral vascular smooth muscle cells. The resting level of [Mg2+]i in these cells was 645 +/- 89 microM before exposure to sex steroid hormones. Exposure of these vascular cells to a low concentration of estrogen (10 pg/ml) failed to interfere with the levels of [Mg2+]i. However, exposure to estrogen, at concentrations ranging from 40 to 200 pg/ml, induced significant loss of [Mg2+]i in a concentration-dependent manner. At a concentration of 200 pg/ml estrogen, the level of [Mg2+]i decreased approximately 30% in comparison with controls. Progesterone produced biphasic effects on the levels of [Mg2+]i, depending on its concentration. Exposure of the cultured cells to a low concentration of progesterone (0.5 ng/ml) resulted in an increased level of [Mg2+]i (from 690 +/- 50 microM to 753 +/- 56 microM, p < 0.05). However, when these cells were exposed to higher concentrations of progesterone (i.e., from 5.0 to 20 ng/ml), the cellular levels of [Mg2+]i were decreased significantly. The higher the estrogen or progesterone concentration, the lower the levels of [Mg2+]i. In contrast, testosterone, a male hormone, didn't produce any significant alteration in [Mg2+]i levels in these cerebral vascular smooth muscle cells. These data indicate that low, physiological concentrations of female sex hormones, estrogen and progesterone, help cerebral vascular smooth cells sustain normal concentrations of [Mg2+]i, which are beneficial to vascular function, whereas high levels of estrogen and progesterone deplete, significantly, [Mg2+]i in cerebral vascular smooth muscle cells, possibly resulting in cerebrovasospasms and reduced cerebral blood flows related to premenstrual syndromes, migraine and stroke risk. Our findings could provide new insight into the mechanism whereby migraine occurs frequently in the late luteal phase in the premenstrual syndrome. In addition, our results demonstrate that female sex steroids but not testosterone (in physiologic concentrations) can exert direct effects on [Mg2+]i in cerebral vascular cells.

Sex-related hormonal influences on pain and analgesic responses

Considerable evidence indicates sex-related differences in pain responses and in the effectiveness of various analgesic agents. Specifically, females are at greater risk for experiencing many forms of clinical pain and are more sensitive to experimentally induced pain relative to males. Regarding analgesic responses, nonhuman animal studies indicate greater opioid analgesia for males, while a limited human literature suggests the opposite. Though the mechanisms underlying these effects remain unclear, the influence of gonadal hormones on nociceptive processing represents one plausible pathway whereby such sex differences could emerge. The present article reviews the complex literature concerning sex steroid effects on pain responses and analgesia. First, nonhuman animal research related to hormonal effects on nociceptive sensitivity and analgesic responses is presented. Next, human studies regarding gonadal hormonal influences on experimental pain responses are reviewed. Several potential mechanisms underlying hormonal effects on nociceptive processing are discussed, including hormonal effects to both peripheral and central nervous system pathways involved in pain transmission. Finally, based on these findings we draw several conclusions and make specific recommendations that will guide future research as it attempts to elucidate the magnitude and importance of sex-related hormonal effects on the experience of pain.

Migraine and ovarian steroid hormones

This chapter reviews clinical and epidemiological data that support a role for ovarian steroid hormones in the migraine syndrome. Changes in the clinical presentation of migraine are discussed on the basis of current knowledge of biochemistry and pharmacology of ovarian steroids. Finally, special treatment considerations of ovarian hormone-sensitive migraine are discussed.

Menstruation, sex hormones, and migraine

All women with migraine are susceptible to the effects of hormonal changes. For a minority with menstrual migraine, fluctuating hormones of the normal ovarian cycle are a specific trigger, particularly during perimenopause. The author proposes that the term menstrual migraine should be restricted to migraine attacks occurring on day 1 +/- 2 days of the menstrual cycle with freedom from migraine during the rest of the cycle. This definition is compatible with the mechanism of estrogen withdrawal. Other mechanisms such as prostaglandin release also may be important for some women. The changing hormonal environment at various stages of life provides further evidence of the role of estrogen in migraine. Treatments that stabilize hormone levels in the form of estrogen supplementation for menstrual migraine, elimination of the pill-free week, and adequate, stable levels of estrogen for HRT, all are associated with an improvement in migraine. The control of the menstrual cycle, however, is extremely complex, and until further studies are undertaken using strict criteria, the mechanism of migraine triggered by hormonal events remains uncertain.

"Menstrual" migraine: towards a definition

"Menstrual" migraine, a term misused by both patients and doctors, lacks precise definition. This dissertation critically reviews papers on the subject and examines the problem from a clinical perspective. A definition is proposed that the term "menstrual" migraine should be restricted to attacks exclusively starting on or between day 1 +/- 2 days of the menstrual cycle; the woman should be free from attacks at all other times of the cycle. This definition, unlike many used previously, links to a specific mechanism; the timing is consistent with oestrogen withdrawal. If this is correct, "oestrogen withdrawal" migraine may be a better term. Future studies, necessary to support or refute these proposals, are suggested.

Menstrual phase-independent retrieval deficit in women with PMS

Memory and attention were evaluated in 19 women with prospectively documented premenstrual syndrome (PMS) and 17 women without PMS. Testing occurred during the late luteal and follicular phases of the menstrual cycle. Estrogen, progesterone, and FSH levels were obtained on testing days for 23 of the women, while mood measures were obtained for all of the women. Repeated measures analysis of variance yielded significant group differences on recall measures, with no differences noted on recognition indices. No significant session or interaction effects were observed. This pattern of results suggests impaired retrieval of learned information coincident with intact encoding. No significant effects were noted for any of the nonverbal memory, attention, or other neurocognitive variables. The obtained data support previous findings of a mild, phase-independent memory impairment in women with PMS and also contribute to a better understanding of the component memory processes involved.

Menstrual migraine is not pathogenetically related to premenstrual syndrome

Facchinetti and colleagues present epidemiological evidence regarding comorbidity between menstrual migraine and premenstrual syndrome, and suggest that premenstural symptoms should be incorporated in the diagnostic criteria for menstrual migraine (1). The crux of the matter, however, should be the concern regarding the nature or biological significance of the common neuroendocrine link of transient and cyclic failure of endogenous opioid activity in both premenstrual syndrome and menstrual migraine patients. Is this a primary event of pathogenetic importance (which would merit inclusion in the definition) or the concomitant side effect of a carefully orchestrated adaptive mechanism?

The association of menstrual migraine with the premenstrual syndrome

To investigate the comorbidity of premenstrual syndrome (PMS) and menstrual migraine, the Menstrual Distress Questionnaire (MDQ) was prospectively administered for two consecutive menstrual cycles to 22 patients with menstrual migraine, 12 cases with migraine without aura and 15 patients with PMS. MDQ scores varied throughout the menstrual cycle in each patient group, the wider changes being shown by patients with PMS. Fourteen menstrual migraine patients and 4 migraine without aura patients achieved diagnostic criteria for PMS over two menstrual cycles. In these patients MDQ scores did not differ from PMS sufferers at any stage of the menstrual cycle. The premenstrual increase of each cluster of PMS symptoms was identical in menstrual migraine and PMS subjects with the exception of negative affect. We suggest that PMS symptoms should be taken into account in the IHS diagnostic criteria for menstrual migraine.