A few months ago one of my patients asked me for painkillers “just to have in my purse, for my period”. I thought she meant cramps but she surprised me: “Migraine, almost always around menstruation”. A minute later, she was going on to the next topic but at the back of my mind, in the “interesting” section, questions started piling up about the connection between menstruation and migraine. And, after a few days, I found the time to read a little bit about the topic. I’m sorry, did I say “a little bit”? It was so interesting that one article led to another and the enthusiasm led me to this post – I just had to let you know 🙂
Before we begin, what’s a migraine anyway?
A migraine is a headache with singular symptoms. It usually appears as a one-sided pulsating pain (and seldom two-sided) involving the temporal region or half of the face. It is accompanied by nausea and vomiting, and sensitivity to light or noise. An untreated episode may last between 2 and 72 hours of medium-high pain. A small part of the people is “gifted” with another element of migraine called aura: sensual symptoms which appear before or at the beginning of the headache, like seeing flashes of light, zigzag patterns, visual spots or skin sensations. It is customary to differentiate between migraine with and without aura as they tend to behave differently. More details will follow later.
How common are migraines? Very much! About 12% of the population will experience a migraine episode at one time or another and it is 3 times as common if you have a relative that suffers from migraines.
It is very tempting to write about the different stages of a migraine, the triggers for its appearance and all its various forms (you probably already realize it is different for each person, as many things are) but if I do that, we’ll never get to the part that joined us in this virtual space. So let’s go on just on the women context for now.
Why do we think there’s a connection between migraine and female hormones?
Let’s start from the common facts: Women experience more migraines than men. While 17% of women after puberty will experience migraine in their lifetime, only 6% of men will get to have the same experience. And why do I emphasize “after puberty”? because before it, as you may have guessed, the gender segmentation shows equal frequency (2.5-4%). This data was the basis for thinking there’s a connection between female hormones, such as estrogen and progesterone, which become more significant during puberty.
The hypothesis of a connection relies on other observations: for many young girls, the first migraine appears at the same time as their first menstruation; some women experience worsening symptoms at specific points of time in their menstrual cycle; improvement of intensity and frequency of the episodes is observed during pregnancy and after menopause. Are you convinced yet?
Opinion today is that estrogen is the main hormone to play a part and that decrease in estrogen levels is one of the significant triggers for a migraine episode. But the low levels are not the only meaningful thing; the mere fact of the decrease, the shifts in the level – is also meaningful. A testimony for that can be found in the fact that after menopause, when estrogen levels are low but stable, the frequency of the migraines decreases. Thinking that stable hormone levels prevent migraine has led to some treatment options, and I’ll get to that later.
By the way, all of the above concerns migraines without aura, as a migraine with aura is a whole different story, perhaps even one that stands on the opposite end of certain aspects. Migraines with aura relate more often to high levels of estrogen and it is unclear yet if changes in estrogen level affect it and in what way.
So, how does all this work with menstruation?
About 80% of people suffering from migraines will be able to identify episode invoking triggers such as mental stress, various foods, lack or excess of sleep and many more. Menstruation is at the distinguished 2nd place in the list of common triggers and it invokes migraine episodes in up to 65% of migraineur women. Symptoms of a migraine during menstruation are the same as any other migraine but they tend to be more powerful, of longer duration and harder to treat.
Yes, I know, the world is not a fair place.
There are two syndromes which connect migraines and menstrual cycles. One is Pure Menstrual Migraine and it comprise 7% of migraineur women. This migraine manifests only around menstruation days, starting from 2 days before the bleeding and up to 3 days afterwards, and accompanies at least two thirds of cycles. Another syndrome is Menstrual Related Migraine in which the connection is less “binding”, as a migraine may manifest in other times of the month as well. This is also the more common type between the two.
Why is it happening? As mentioned above, this is due to a decrease in estrogen levels which parallels menstrual bleeding.
By the way, the pattern of increase and decrease of hormones during the month starts emerging in the body even before the first menstruation; this may explain a monthly pattern of migraines in some young girls who didn’t have their first menstruation yet. This principle works not only for the natural cycles but also with hormonal contraceptives. For example; in the days\week off the contraceptive pills, in the week off NuvaRing or the week off contraceptive patch; all of which are times when migraines become more common.
Hold on, is it OK to use pills?
For women who suffer from migraines without aura it is ok to use pills; sometimes it is even part of the treatment (oops! Sorry for the spoiler). However, pills shouldn’t be used by women who suffer from migraines with aura as some researches indicated a small increase in the risk for a stroke, especially so in smoking women. In general, migraine under the use of pills tend to be milder, but we should be careful with it as there is a small portion of women who may experience a stronger migraine, and some women report that pills were the trigger for their first episode. Currently, we cannot predict the reaction so we’re left with trial and error.
On a related topic: What happens around pregnancy?
Migraines without aura tend to improve during pregnancy and recurs after giving birth. The relation is at least partially hormonal and partially influenced by changes in sleep, mood and unordered eating after the birth. Yes, the baby’s too 😉
I mentioned very briefly the relation between migraines and menopause; it is a complex issue. The menopause itself is preceded by 4-7 years of perimenopause; the period of time which precedes the final cycle. During this time there are frequent and “messy” increases and decreases in hormone levels, and since decrease in estrogen levels triggers a migraine you can understand that this is a challenging time regarding migraine episodes.
But let’s look at the menstrual cup half full (Sorry J). During the time after menopause frequency of migraines decreases in almost half and there are less nausea and vomiting. Is improvement unique for women with menstrual migraine? Logic says this would be a probable assumption but there’s not enough research to determine. Still, hormones are not the only factors influencing frequency and severity of migraines; menopause may carry with it other triggers such as sleep disturbances, muscular stress and mood swings which may worsen migraines.
Well then, is there a treatment?
The basic treatment for migraine is always the same and always include avoiding triggers, specified treatment during an episode (rest in a quiet, dark room, various drugs) and a prolonged preventative treatment when the specified treatment isn’t helpful. Complementary and behavioral treatments have some value in relieving a migraine, specifically biofeedback, relaxation techniques and acupuncture.
One option to prevent migraine is hormonal treatment. With regular cycles a supplement of estrogen can be used a couple of days before the bleeding and up to 5 days afterwards, to prevent decrease in hormone levels. In much the same way, a woman who uses a hormonal contraceptive can skip the week off between the packages of pills/ ring/ patch and thus skip the migraine (some other side effects may appear with continuous use, such as feeling bloated or puffiness).
The same principle applies around menopause and whoever takes HRT (Hormone Replacement Therapy) can make it into a continuous treatment (which is also the accepted protocol currently). Another option is to convert the manner of receiving hormones, as it seems that giving hormones trans-dermally (via skin) or trans-vaginally (via vagina) triggers less migraines than pill popping. Another tip: if you suffer from morning migraines it is best to take the hormonal treatment before you go to sleep.
Are there any more factors to consider in adjusting treatment, besides hormones?
Well, since you asked so nicely, of course there are! One group of pain killers which are also anti-inflammatory is called Mefenamic Acid and, according to research, it is a little bit more effective when treating menstrual migraine. It also works well for other menstrual related pains and thus worth considering. However, it is not in common use neither in Israel nor abroad and it is yet unclear if the little difference is worth the effort.
When adjusting a treatment, planning a family should be taken into account as some drugs are prohibited during pregnancy. If you’re planning to have a child, let your doctor know about it so your migraines can be treated without unnecessary risks.
Is there another connection between women and migraines except for hormones?
Yes. Some other pain syndromes may accompany migraines, such as fibromyalgia and irritable bowel syndrome, both of which are also more common in women. By the way, irritable bowel syndrome is also influenced by menstruation and tend to get worse during days of bleeding. Another connection is the relation between chronic migraine (which has nothing to do with estrogen levels) and endometriosis, but the nature of this relation is yet unclear.
Let me conclude my writing with a bold move: I waive the traditional ending paragraph and give it over to you. You are welcome to share personal experiences by filling up a short survey ↓ or by commenting on this post.
For easier reading and clarity, I treated biological females as “women”. Please forgive me for that. You are very welcome to send offers of better pronouns which will respect all identities.
“Sex and Gender Aspects in Clinical Medicine”, edited by Sabine Oertelt-Prigione & Vera Regitz-Zagrosek
Pathophysiology, clinical manifestations, and diagnosis of migraine in adults
Migraine fact sheet – Women’s Health.gov