Women, Migraine, and the Estrogen Connection

5 Facts About Women and Migraine That May Surprise You

Migraines Prior to Menstruation and Menopause Are Common
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Migraine affects over 36 million Americans, and as you may already suspect, women are affected more than men. This gender discrepancy in migraine occurrence is attributed to the natural fluctuation of the female sex hormone estrogen.

More specifically, "A decline in estrogen levels increases the chances for a migraine attack to occur," says Matthew S. Robbins, MD, Associate Professor of Clinical Neurology at the Albert Einstein College of Medicine and American Headache Society board member.

"Migraine frequency and severity may be more common in women during periods of declining estrogen, such as around the time of your period, after delivering a baby (especially if not breastfeeding), and during menopause when levels are highly irregular," adds Dr. Robbins.

Let's explore five facts about women and migraine and unveil the twists and turns that make this hormone-based connection a fascinating, yet burdensome phenomenon.

Menstrual Migraine May Not Respond to Your Usual Medication

Menstrual migraine occurs within a finite window of time called the perimenstrual period, which begins two days prior to the start of menstrual flow and ends around day three of a woman's period. The reason for this fixed time frame is that menstrual migraine is believed to be triggered by the drop in estrogen levels that occurs just prior to a woman starting her period.

The tricky part about a menstrual migraine is that it's often more severe and lasts longer than a migraine that occurs during other times of the month.

This can make treating menstrual migraine a bit more of a delicate, trying process. But be assured, there are a few strategies that you and your doctor can implement so you get the relief you deserve.

Your first strategy is to jump on treating your migraine attack as early as possible. In other words, if simple measures like resting in a dark room or applying a cold pack are not easing your pain, it's best to move forward with a triptan, a medication used to treat moderate to severe migraine.

In addition, it's reasonable to take a triptan in combination with a nonsteroidal anti-inflammatory (NSAID) like ibuprofen or Aleve (naproxen). Your doctor may even recommend a prescription combination medication like Treximet (sumatriptan/naproxen sodium).

A second strategy is to prevent a menstrual migraine from occurring in the first place. A woman may opt to take a preventive medication like a NSAID or the long-acting triptan, Frova (frovatriptan) five or six days prior to menstruation beginning. Another option is magnesium, although magnesium is usually taken about two weeks prior to a woman's period beginning.

Alternatively, to get to the root of the "estrogen decline," some women opt to take a form of estrogen (for example, an estrogen skin patch or pill) during the week prior to menstruation. However, if your menstrual cycles are not regular, continuous birth control may be a better strategy so there is no natural estrogen drop.

You Should Talk to Your Doctor If You Are Taking Birth Control Pills

It's true that women who take birth control pills have a higher risk of having a stroke compared to women who are not taking birth control pills. While this may initially sound alarming, most women who take birth control pills are young women and stroke is overall very rare in this population.

That said, women on birth control pills who are at the highest risk for stroke are those who have other risk factors (for example, women who smoke or have high blood pressure)—and studies suggest that a migraine with aura is also a risk factor (although the scientific evidence is not as robust as with the other risk factors).

The bottom line here is if you have migraine with aura, use of some birth control pills may not be safe, particularly if the estrogen content is high. To be safe and proactive, you should speak with your gynecologist, neurologist, or primary care physician to better understand the risks and benefits.

You May Experience a Migraine Breather During Pregnancy

The added bonus of nurturing your little one during pregnancy is that you may experience a migraine breather, especially during the second and third trimester, when your estrogen levels are at their peak. In fact, up to 70 percent of women with a history of migraine note improvement over the course of their pregnancy.

That said, about five percent report a worsening of their migraine attacks, and the rest report no change. Interestingly, women who experience menstrual migraine and migraine without aura are most likely to note migraine improvement during pregnancy.

The downside of this "migraine getting better during pregnancy" phenomenon is that after pregnancy, during the postpartum period, your migraine attacks may come back with a vengeance. Although, research shows breastfeeding may be protective. This makes sense, too, as breastfeeding stabilizes estrogen levels in the body.

The bottom line here, comments Dr. Robbins, is that, "Migraine management in pregnancy actually starts well before conception to understand which non-medicine approaches during pregnancy should be prioritized, and which medical therapies may be both safe and effective."

You May Have Migraine Worsening in Perimenopause

Menopause is a point in time when a woman stops having menstrual cycles for 12 months. What does this mean biologically? It means that a woman's ovaries have stopped producing the hormone estrogen.

Perimenopause is the period of time just prior to menopause when a woman's ovaries are beginning to malfunction and not produce as much estrogen as they did during a woman's reproductive years. These fluctuating (and generally lower) estrogen levels are what cause the classic symptoms of perimenopause like hot flashes and changes in menstruation.

In addition to these unpleasant symptoms, women with migraine may develop more headaches during perimenopause. According to a study in Headache, the risk for high-frequency headaches (defined as a headache 10 or more days per month) increased by 60 percent in perimenopausal women with migraine, as compared to premenopausal women with migraine.

The" why" behind the higher frequency of migraine in perimenopause is not entirely clear, but experts suspect the erratic fluctuation of estrogen levels as the primary culprit.

The good news is that there are ways to ease your migraine pain as you embark on the journey of menopause. Many women find relief with various hormone therapies which stabilize estrogen levels.

Your Migraine May Improve (or Worsen) in Menopause

Research is conflicting when it comes to deciphering the link between migraine and menopause. In other words, many studies suggest migraine in women gets better after menopause, and yet other studies suggest it worsens, especially if a woman has chronic migraine.

What does this mean? It's likely there are more factors involved than just estrogen when it comes to postmenopausal migraine. For some women, the stable (albeit very low) levels of estrogen in their bodies after menopause may be the reason behind their migraine vanishing.

On the flip side, other women may notice more migraine attacks after menopause, and this increased migraine frequency is likely not directly linked to estrogen. For instance, increased stress, sleep disturbances and mood changes like depression are common in perimenopause and menopause, and these factors (on top of a woman's already present vulnerability to developing migraine) may trigger more attacks.

Another classic example in menopause (and middle age, in general) is muscle and joint pains. If a woman takes too many pain medications to combat both her migraine and joint pain, this can trigger a headache disorder called medication overuse headache. While this is not a migraine, it can complicate the picture (imagine a headache on top of another headache).

Lastly, if your doctor suspects that estrogen depletion from menopause is the trigger behind your migraine attacks, hormone replacement therapy may benefit you. Although, like with menstrual migraine, taking estrogen may worsen migraine in some women—another example of the migraine-estrogen conundrum.

A Word From Verywell

Migraine is a debilitating disease, and managing it can be challenging—but there is help available. Please seek care from a healthcare professional who has expertise in treating headaches and migraine.

Stay optimistic, as the treatment of migraine has gained significant momentum in the last couple of years. There are more migraine therapies available today, and even more in the pipeline for the future than ever before.

Sources:

Headache Classification Committee of the International Headache Society. "The International Classification of Headache Disorders: 3rd Edition (beta version)." Cephalalgia 2013;33(9):629-808.

MacGregor EA. Headache in pregnancy. Neurol Clin. 2012 Aug;30(3):835-66.

Martin, V.T., Pavlovic, J., Fanning, K.M., Buse, D.C., Reed, M.L., & Lipton, R.B. (2016). Perimenopause and menopause are associated with high frequency headache in women with migraine: Results of the American migraine prevalence and prevention study. Headache.Feb;56(2):292-305.

Martin V. Migraine and the menopausal transition. Neurol Sci. 2014 May;35 Suppl 1:65-9.

Roach RE, Helmerhorst FM, Lijferng WM, Stijnen T, Algra A, Dekkers OM. Combined oral contraceptives: the risk of myocardial infarction and ischemic stroke. Cochrane Database Syst Rev. 2015 Aug 27;(8):CD011054.

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