The Relationship Between Sexual Orientation or Gender Identity and Migraine
Medically reviewed by: Dr. Anna Pace
Terminology: What is Sexual and Gender Diversity?
Sexual diversity is an umbrella term used by researchers to describe the spectrum of sexual orientations beyond heterosexual. The term includes people who are lesbian, gay, bisexual, queer, asexual and more. Gender diversity is an umbrella term for people whose gender identity is not cisgender; different from their sex assigned at birth. The term includes people who are transgender, non-binary, genderfluid and more. A person’s gender does not determine a person’s sexual orientation. Researchers are beginning to look at the intersections of sexual and gender diversities and migraine. At present there are a few studies that look at sexual diversity, and one that includes gender diversity.
Disparities Found in Migraine and Sexual and Gender Diversity
There is a higher prevalence of migraine in people who do not identify as strictly heterosexual or cisgender. A survey of sexually and gender diverse people found that 33.9% of the respondents reported a migraine-like headache using ID migraine.1 This is a significant increase compared to an average of 14% in the total population having migraine.2 A different study on U.S. adults categorized sexual orientation into three categories: exclusively heterosexual; mostly heterosexual but somewhat attracted to people of one’s own sex; or lesbian, gay, or bisexual.3 The prevalence of migraine was the highest among people who were lesbian, gay or bisexual (30.7%) followed by people who reported being mostly heterosexual (30.3%) and lastly by people who reported being exclusively heterosexual (19.4%).3
Another study subdivided the larger grouping and found the prevalence of severe headache or migraine in the U.S. was the highest among bisexual women (36.8%), followed by lesbian women (24.7%), bisexual men (22.8%), heterosexual women (19.7%), gay men (14.8%), and heterosexual men (9.8%).4 A Canadian study found gay and bisexual men had 50% higher odds of migraine compared to heterosexual men but curiously, no association for lesbian or bisexual women.5 Recent studies suggest that sexual and gender minoritized individuals have a higher rate of migraine and further studies are needed to understand these disparities.
Potential Reasons Why Sexually and Gender Minoritized People Are More Likely to Have Migraine
Social stressors and experiences of discrimination affect migraine severity, disability and frequency. This has been looked at predominantly in cisgender women. Researchers are beginning to focus more on the impact of sexual and gender minoritization in migraine. People with migraine who identify as transgender or gender-diverse often face stigma and discrimination, and studies have proposed that gender minoritized stress (which is related to stigma and discrimination) is a key player in the experience of pain in these individuals.6
A study of migraine, trauma and discrimination in sexually and gender-diverse people began to look at how the cumulative effect of adverse childhood experiences and discrimination over a longer period of time manifests in the body, particularly with migraine. The study found that higher numbers of types of traumatic and/or discrimination events experienced by an individual were associated with increased migraine disability.7
The Importance of Social Safety
The fact that there is repeated stress and/or traumatic events from being marginalized has been discussed in research for a number of decades and has been proven to have a negative impact on mental health, but limited physical health outcomes have been identified. Some researchers are looking to the social safety theory to fill in this gap.
Social safety refers to reliable social connection, inclusion, and protection, which are core human needs that are harmed by stigma.8 Social safety theory states people who are marginalized have better health outcomes if they have social safety.8 This theory may explain why the highest prevalence of severe headache or migraine is for bisexual women and lowest for heterosexual men, since there is the most social safety for heterosexual men and the least for bisexual women.
Social safety theory says the absence of social safety is just as harmful on the health of stigmatized people as the presence of marginalized stress or trauma.8 When a person feels unsafe, they are constantly vigilant for threats, and increasingly monitoring of self and others, which can lead to negative long-term effects on cognitive, emotional, and immunological functioning. Examples of threats to social safety would be seeing or experiencing bullying or threats of sexually and gender diverse people, versus seeing people condemn this mistreatment or discrimination. Speaking out against discrimination is one way to contribute to social safety.
Future Areas of Research
Due to the limited amount of research for the LGBTQIA+ population, more research is encouraged to improve care. One study states a “systematic collection of sexual orientation and gender identity in electronic health records, population health surveys, and patient registries would be an important step toward exploring the role of traumatic experiences in migraine using an intersectional framework and thereby improving neurologic health equity in this underserved community.”7
Dr. Rosendale, principal investigator for Migraine, Migraine Disability, Trauma, and Discrimination in Sexual and Gender Minority Individuals, states: “And I think the next frontier is really trying to understand how an individual comes to the healthcare system or comes into and kind of lives their life, holding all of the various identities that they have, right? So not only just focusing on sexual orientation, gender identity, gender expression, but also how their race, their socioeconomic status, their you know, access to housing or not and how all of those kind of piece together I think is going to be another vanguard of of research that hopefully we can get to very shortly.”9
A Note to Patients and Providers
For providers, enacting policies to recognize and affirm sexual and gender diversity can create social safety and reduce health disparities. Research on sexual orientation, gender identity, and disparities in migraine highlights the need for providers to think about a patient’s life experience, as well as their mental health. On the podcast Talking Head Pain, Dr. Rosendale recommends researchers and/or health care providers ask open minded inclusive questions to understand someone’s life experience, what they have experienced and what they are currently experiencing.9 For patients, it is important to work with providers you feel safe with. For patients and providers, we can improve health outcomes by creating and seeking more safe spaces where people do not have to constantly monitor how they speak or look to avoid being harmed. If we encourage people to speak up for each other, that’s creating social safety and that can create better health.
- Finding an LGBTQIA+ Provider
- Tips for Finding an LGBTQIA+ Provider
- LGBTQIA+ Therapist Directories and Crisis Resources
- Tips for Communicating with and for LGBTQIA+ Communities
- Education for healthcare providers – National LGBTQIA+ Education Center
- Migraine in the LGBTQIA+ Community: A Conversation with Dr. Nicole Rosendale
- Migraine in the LGBTQIA+ Community: A Panel Discussion
- Mount Sinai Transgender Headache Medicine Program
- Migraine, Migraine Disability, Trauma, and Discrimination in Sexual and Gender Minority Individuals Nicole Rosendale, Elan L. Guterman, Juno Obedin-Maliver, Annesa Flentje, Matthew R. Capriotti, Micah E. Lubensky, Mitchell R. Lunn Neurology Oct 2022, 99 (14) e1549-e1559; DOI: 10.1212/WNL.0000000000200941
- Stovner, L.J., Hagen, K., Linde, M. et al. The global prevalence of headache: an update, with analysis of the influences of methodological factors on prevalence estimates. J Headache Pain 23, 34 (2022). https://doi.org/10.1186/s10194-022-01402-2
- Nagata JM, et al. Disparities across sexual orientation in migraine among US adults. JAMA Neurol. 2021;78(1):117-118. DOI: 10.1001/jamaneurol.2020.3406
- Heslin, K. Explaining Disparities in Severe Headache and Migraine Among Sexual Minority Adults in the United States, 2013–2018. 2020 https://doi.org/10.1097/NMD.0000000000001221
- 5. Hammond, et al. Health Behaviors and Social Determinants of Migraine in a Canadian Population-Based Sample of Adults Aged 45-85 Years: Findings From the CLSA. 2019 https://doi.org/10.1111/head.13610
- Pace, A., Barber, M., Ziplow, J. et al. Gender Minority Stress, Psychiatric Comorbidities, and the Experience of Migraine in Transgender and Gender-Diverse Individuals: a Narrative Review. 2021 https://doi.org/10.1007/s11916-021-00996-7
- Rosendale, et al. Migraine, Migraine Disability, Trauma, and Discrimination in Sexual and Gender Minority Individuals. 2022 https://doi.org/10.1212/WNL.0000000000200941
- Diamond LM, Alley J. Rethinking minority stress: A social safety perspective on the health effects of stigma in sexually-diverse and gender-diverse populations. Neurosci Biobehav Rev. 2022 Jul;138:104720. doi: 10.1016/j.neubiorev.2022.104720. Epub 2022 Jun 2. PMID: 35662651.
- Rosendale and Coe. Migraine in the LGBTQ+ Community: A Conversation with Dr. Nicole Rosendale. Talking Head Pain https://ghlf.org/talkingheadpain/#1660739266386-decbaa36-2e35
Yuri Cárdenas lives in Oakland, California, with their assistance dog Katsu. They have lived with chronic migraine for ten years and are passionate about reducing stigma and helping people live a better life while chronically ill. They advocate to end disparities in health and healthcare, and see safe spaces for everyone with migraine.