Hormones, Menstrual Migraine & Treatment Protocols
The link between hormones and migraine disease is undeniably strong. The neurological disorder predominantly affects women of childbearing age, particularly during times of hormonal shifts: puberty, menstruation, pregnancy, and menopause6. The ebb and flow of sex hormones such as estrogen and progesterone can make treating these migraine attacks tricky, but there are some medications and therapies that can help combat the pain.
The Sex Hormones in Men and Women with Migraine Disease
When it comes to primary headache disorders, each condition seems to have a sex-specific prevalence. Migraine is most common in women, while cluster headache impacts more men. “Estrogen Withdrawal Hypothesis” is the theory as to why migraine disease affects women most4.
A 2014 review of studies on migraine and estrogen shows the significant impact sex hormones have on this condition. Imaging from MRIs has revealed functional and anatomical differences in the brains of men and women with migraine disease as well as those who have migraine versus those who don’t. Hormone levels change throughout your life, whether you’re male or female, but women see much more drastic and frequent alterations in estrogen. Migraine attacks tend to arise when significant estrogen drops happen during menstruation and menopause².
The role of estrogen in migraine disease is clear when considering that women have this neurological disorder 2-3 times more than men, and migraine prevalence is lower before puberty and after menopause. The ovaries produce estrogen in women who are not pregnant. In men, estrogen coexists with testosterone in much lower quantities than young women. These levels stay relatively consistent and decline at a slower rate with age in men. The most potent estrogen type (Estradiol) is three times higher in 60-year-old men than women who are post-menopausal². This sex hormone plays a role in pain processing and memory, which explains why some experience memory issues during estrogen declines such as menopause³.
How Puberty & Menstruation Impact Migraine Disease
Migraine disease spikes in young women around puberty and continues through their 40s—the most active years with school, work, and childbearing. Menstrual-related migraine affects up to 70% of women starting around 2-5 days before menstruation. Some may not notice the connection because the migraine attacks begin before their period. Menstrual migraine is more specific, impacting just 5-10 percent of women strictly during menstruation1.
Menstrual migraine can be quite debilitating. Missed days of school or work are standard as these attacks are considered more painful, last longer, and are more resistant to treatment5. Migraine attacks often come on several days before or during a period, further pointing to estrogen fluctuations being the culprit6. A variety of research suggests that addressing this decline in estrogen during menses and other major hormonal shifts in a woman’s life can prevent menstrual migraine and reduce migraine with aura².
These variations of migraine disease point to estrogen drops but also indicate progesterone levels play a part. That’s because these attacks happen around menstruation and not during ovulation. Both are parts of the luteal phase involving estrogen decreases but progesterone levels only drop during a period1. Progesterone increases if one becomes pregnant during that cycle, and pregnancy seems to reduce migraine frequency in up to an astonishing 90% of women7.
Hormonal contraceptives introduced during a young woman’s life have shown to increase risk for stroke and cardiac disease in people with migraine, specifically those who have migraine with aura. Combined oral contraceptives elevate that risk for ischemic stroke even more and may worsen migraine attacks6. Physicians treating women with migraine should caution them about this risk, but the issue is that menstrual-related migraine often goes undiagnosed. One reason is that the condition’s diagnostic criteria doesn’t require you to have migraine attacks during every menstrual cycle, only two out of the last three1.
Hormone replacement therapy can also have severe consequences for people with migraine, which is sometimes given to menopausal women6. Luckily, as estrogen levels steady during menopause, migraine disease seems to improve, and attacks are fewer and farther in between².
Treating Menstrual-Related Migraine and Menstrual Migraine
Treating menstrual-related migraine can be a simple process if the attacks occur within the same 5-7-day window each month. Instead of daily medication, many women can take short-term preventive treatments such as triptans during their menstrual cycle where the attacks come on¹. This protocol is helpful only if your menstrual cycle is predictable and it requires a headache diary to pinpoint the days to start treatment5.
The best evidence for aborting migraine attacks around menstruation is with the medication, rizatriptan. Research shows it can reduce or eliminate the pain within two hours in 63% of patients. The next in line are other triptans, including sumatriptan, almotriptan, and zolmitriptan, followed by NSAIDs5.
Short-term prophylactic treatment for migraine attacks related to hormone changes involves starting a treatment a few days before an expected migraine or menstruation. Frovatriptan is “Level A” guidance by the American Headache Society and the American Academy of Neurology for Menstrual Migraine. One study shows that 57% of patients were attack-free for three menstrual cycles. This treatment protocol involves taking frovatriptan twice a day, beginning two days before your period, and continuing for five days. If you have break-through pain, there is additional dosage that can be added. *This protocol should be done under the supervision of your doctor. The study showed frovatriptan was particularly beneficial to women who had true menstrual migraine and those who didn’t respond to other treatments5.
An estrogen patch or 3-month contraception is another treatment option for these migraine attacks. Still, it’s important to remember that compounds that contain estrogen can increase the risk of vascular disease¹.
While there are several medications for treating hormone-related migraine attacks, treatment doesn’t have to stop with pharmaceuticals. There are neuromodulators, relaxation techniques, biofeedback, and cognitive behavioral therapy options for disease management1. Migraine is a brain disorder and requires various options in your toolkit to achieve more pain relief and a better quality of life.
- Byrne, J. (2018, April 27). Managing migraine in women often means managing hormones. Retrieved November 12, 2020, from https://www.healio.com/news/endocrinology/20180426/managing-migraine-in-women-often-means-managing-hormones
- Chai, N. C., Peterlin, B. L., & Calhoun, A. H. (2014). Migraine and estrogen. Current Opinion in Neurology, 27(3), 315-324. doi:10.1097/wco.0000000000000091
- Carpenter, S. (2001, January). Does estrogen protect memory? Retrieved November 12, 2020, from https://www.apa.org/monitor/jan01/estrogen
- Delaruelle, Z., Ivanova, T. A., Khan, S., Negro, A., Ornello, R., Raffaelli, B., . . . Reuter, U. (2018). Male and female sex hormones in primary headaches. The Journal of Headache and Pain, 19(1). doi:10.1186/s10194-018-0922-7
- Hullett, P. W., MD, PhD, & Maasumi, K., MD, MS. (2017, October 17). Treating Menstrual Migraines. Retrieved November 12, 2020, from https://www.neurologylive.com/view/treating-menstrual-migraines
- Sacco, S., Ricci, S., Degan, D., & Carolei, A. (2012). Migraine in women: The role of hormones and their impact on vascular diseases. The Journal of Headache and Pain, 13(3), 177-189. doi:10.1007/s10194-012-0424-y
- Weitzel, L. (2019, April 8). Pregnancy and Migraine Medications. Retrieved November 12, 2020, from https://www.migrainedisorders.org/pregnancy-and-migraine-medications/
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