113 Migraine with and without aura in relation to the menstrual cycle 5 DISCUSSION We found an increased risk of migraine attacks without aura during the perimenstrual window in both women with MO and MA. In contrast, no relation with the perimenstrual window was found for migraine attacks with aura. Our findings contribute to the hypothesis of differential effects of sex hormones on the trigeminovascular system (migraine headache) and the initiation of cortical spreading depolarization (CSD) (aura). Menstruation has long been linked to increased susceptibility of migraine attacks without aura, which is suggested to result from the drop in estradiol levels prior to menstruation, but there was still ambiguity about its relation to attacks with aura.1, 2, 8, 9, 14 The current ICHD-3 classification therefore includes criteria for both menstrual migraine with and without aura.4 Our data clearly indicate that the perimenstrual window is associated with increased susceptibility exclusively to migraine attacks without aura, both in women with MO and MA. Interestingly, prevalence of menstrual migraine was similar among women with MO and MA as the majority of MA patients also suffer from attacks without aura. For future editions of the ICHD criteria, we would therefore recommend specifying that it is exclusively migraine attacks without aura that are perimenstrual attacks, also in women who additionally experience migraine attacks with aura. A further subtype distinction between menstrual migraine with and without aura seems unnecessary, as the diagnosis of menstrual migraine is based on perimenstrual attacks, which are not accompanied by auras as we showed in this study. Naturally, diagnosis of MA can coexist with menstrual migraine, since we demonstrated that MA can be accompanied by (perimenstrual) attacks without aura. All our recommendations for defining menstrual migraine in future editions of the ICHD are summarized in Table 5.3
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