How well does standard migraine prophylaxis work in perimenopausal women averse to hormone therapy?
—Paula Y. Carruthers, MD, Sherman Oaks, Calif.

This is problematic because doses of preventives sufficient to forestall significant headache disability during menstruation are often not perceived as useful in patients with minimal headaches at other times during the month. My approach to this has varied over the years, but what seems to work best and is best supported by clinical studies is to dose naproxen about 200 mg once or twice a day for the day preceding and for the first three or four days of menses. To this I add a standard triptan dose once or twice a day as needed for headaches of even moderate severity. This approach is limited to menstrual-associated migraine and works less well for true menstrual migraine, marked by headaches that occur only after Day 1 of menses.
—Douglas Dulli, MD, associate professor of neurology, University of Wisconsin Medical School, Madison (108-8)

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