168 Chapter 8 cycles. For the migraine group, diagnosis of menstrual migraine was validated with the Leiden e-headache diary, an AI-based tool that diagnoses migraine days through a thorough validated algorithm.14-16 Migraine attacks had to occur on days -2 to +3 of menstruation in at least two out of three menstrual cycles to meet the criteria for menstrual migraine.13, 17 Participants with migraine were excluded if chronic migraine or medication-overuse headache was identified during the screening period, or if they did not fulfill the criteria for menstrual migraine. For both groups, women were excluded if they smoked, had a BMI <18·5 or >30 kg/m², used corticosteroids, oral contraceptives or other hormonal treatments. Additionally, women who were pregnant, breastfeeding, or had conditions affecting sex hormone level, e.g. polycystic ovary syndrome, were excluded. To ensure menstrual cycle regularity, all participants recorded at least three consecutive menstrual cycles before the start of hormone measurements. Since menopausal transition is characterized by increased cycle variability, participants with a persistent difference of ≥7 days in consecutive cycle lengths were excluded. Following blood sample collection, participants were excluded if diagnosed as perimenopausal, based on assessment of low plasma anti-Müllerian hormone (AMH) levels (0·01–0·03 µg/L) and elevated folliclestimulating hormone (FSH) levels (>25 IU/L), ensuring all participants were classified as Stage -4 (peak reproductive age) of the STRAW+10 criteria.18 The study is performed in accordance with the declaration of Helsinki Ethical Principles and Good Clinical Practices and was approved by the local and national ethics committees (NL74161.058.20). All participants provided written informed consent. Study design This is a longitudinal prospective cohort study among women with menstrual migraine and controls conducted between August 2018 and October 2024. Participants gave written informed consent during the inclusion visit at the Leiden Headache Center. Biometric data, including height, weight, blood pressure, waist circumference, were recorded, and neurological examination was performed to screen for abnormalities. Throughout the study, participants with migraine were instructed to complete the Leiden validated headache e-diary, which also includes questions about menstrual bleeding.14-16 Healthy controls were also required to track their menstruation dates. Participants received a Clearblue Digital Ovulation Test Kit with detailed instructions. They were instructed to begin testing on the fifth day of menstruation, using first morning urine, continuing daily until a LH surge was obtained (Figure 1).
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