3 years on Ajovy, convinced it just wasn’t strong enough. Then my neuro asked “which days exactly?” Turns out 95% of my migraines happen in the 5 days before my period. Rest of cycle: fine. That one week: bedbound.
So it’s predictable, which sounds good until you realize the side effect: Ajovy doesn’t hit right in that window. Half-dose effect. Prodrome’s different too - more nausea, less visual aura. Triptans still work but burn through them way faster.
Neuro thinks hormonal drops lower my pain threshold regardless of CGRP coverage. Maybe. But I can’t find anyone actually talking about preventives being weaker during specific cycle weeks. Does this happen to anyone else or should I be asking my neuro about taking extra triptans that week?
so your neuro’s framing of a lowered pain threshold is the right way to think about it. The pattern you’re describing is a well-documented one for menstrual migraine, and it’s not so much that the Ajovy is “weaker” as that the underlying trigger is stronger during that window. The premenstrual drop in estradiol is a potent sensitizer of the trigeminal system. Your CGRP blockade from the Ajovy is likely steady, but the stimulus it has to fight against gets turned up to eleven for those few days.
The system is just fundamentally more irritable, and the dose that’s sufficient for the rest of the month gets overwhelmed. This is a really good example of a signal that trial endpoints often aren’t powered to catch. A trial measures the change in mean monthly migraine days. A drug can absolutely succeed on that endpoint while still failing predictably for a subgroup during a specific hormonal window.
You’ve done the hard work of identifying the pattern with your own tracking, which is exactly the data your neuro needs to talk about strategies for that specific five-day window. It’s a very real phenomenon.