Sasha Milbeck and Sophia Lee, National Center for Health Research
The pain from a headache can be throbbing, dull, or constant, and it can distract from everyday activities. Did you know that there are more than 150 different types of headaches (for example migraines, cluster headaches, and tension headaches), and many of these headaches affect females and males differently? For example, women are more likely to experience all types of migraine headaches. Migraines often cause a deep throbbing pain, usually on one side of the head, which can last several days. There are numerous types of migraine headaches, and some occur with aura, which means there are sensory disturbances, such as flashes of light, vision changes, and tingling, along with the pain. This article will focus on menstrual migraines, which occur during or around the time of a monthly period and can be accompanied with aura.
While the exact cause of different types of migraine is still unknown, researchers speculate that migraines are the result of abnormal brain activity affecting nerve signals, chemicals, and blood vessels. Estrogen, the female sex hormone that fluctuates in levels throughout the menstrual cycle, is involved in regulating these specific chemical pathways. That is why researchers study the role that estrogen plays in determining whether a migraine will occur, and its connection to the menstrual cycle.
This article will describe how changes in hormones can affect migraines in women, as well as the different treatments that exist. Migraine research is still a new field, and at this time treatments usually depend on each patient and their specific symptoms.
Migraines and the Menstrual Cycle
The sex differences in migraine rates begin at puberty, when females begin to menstruate and experience changes in female sex hormones. While both males and females experience fluctuations in hormones (especially during puberty), some hormonal changes are unique to women and occur during life stages such as menstruation, pregnancy, and menopause. These normal changes in hormones can lead to migraines, causing further pain and discomfort. Migraines can also be related to taking or stopping supplemental hormones, such as hormonal birth control or hormonal replacement therapy for transgender and postmenopausal women.
After puberty, females in the United States suffer from all types of migraines at a rate three times higher than in males, and the migraines are more frequent around the time of their periods.[1,3] Among women with migraines, one out of six report the migraines started at puberty and they typically go away after menopause, presumably because of changes in estrogen and other hormones at those times.[3,4]
When diagnosing menstrual migraines, there are two types: 1) pure menstrual migraines, which only occur during menstruation, and 2) menstrual-related migraines, which are the more common type of menstrual migraine and can occur during menstruation as well as the rest of the cycle. Menstrual migraines are unique to each patient and there is no set “type” of migraine that patients will experience around the time of their periods. For example, some patients may experience aura, while others do not. Physicians look at different factors such as hormonal imbalances, genetics, diet, and history of other headaches to determine treatment.
Estrogen: What is it and How Does it Affect the Body?
Estrogen and progesterone are the two major sex hormones that females have. During puberty, estrogen is responsible for the growth of the breasts, growth of pubic and underarm hair, and the start of the menstrual cycle. Men also have estrogen, but at much lower and more stable levels, which decline more gradually throughout life.
The levels of estrogen in women fluctuate throughout life, and while the changes are normal, they can be associated with uncomfortable side effects such as changes in mood, weight, sexual desire, and sleep schedule. Normal major changes in estrogen occur at least 4 separate times in a woman’s life. These include: 1) just before her period (coinciding with a drop in estrogen that will usually occur monthly); 2) during pregnancy (estrogen increases throughout the trimesters); 3) during the perimenopausal phase where the female body makes the natural change to menopause and there is a significant drop in estrogen; and 4) after menopause, when estrogen levels are consistently lower.
Changes in hormone levels will differ in every person. On top of the normal changes in hormones mentioned above, both men and women can also experience hormonal imbalances due to other medical conditions. Thyroid problems, diabetes, eating disorders, and polycystic ovarian syndrome (a condition in women causing ovarian cysts and excess testosterone) can cause hormone levels to fluctuate dramatically and result in migraines and other symptoms.
Estrogen and Migraines
Estrogens affect the release of endorphins, which are chemicals produced by the body to relieve stress and pain. Additionally, increased estrogen will produce more of the chemical serotonin, which narrows blood vessels in the body. When estrogen levels fall, so do serotonin levels, which causes blood vessels to dilate.[7,8] This can cause blood vessels to become inflamed and affect the body’s pain receptors, which can then lead to the throbbing pain experienced during a migraine. In women, significant drops in estrogen typically occur right before a monthly period and when starting menopause. Studies where estrogen is lowered in women show a correlation with a spike in migraine attacks.[3,7] For example, in one study, women undergoing in vitro fertilization were given a hormone that lowered estrogen levels and consequently, the frequency of migraines increased. In another study, cessation of birth control pills caused headaches, due to lowered levels of estrogen and serotonin. In contrast, when estrogen levels are high (such as during pregnancy), headaches are less likely. A study of 1,300 women who suffered from migraines found that 67% of the women noted that their migraines disappeared during pregnancy. Nevertheless, some researchers believe the main culprit causing migraines is not low levels of estrogen, but dramatic changes in levels of estrogen.
Treatments for Migraines
There are numerous medications and treatments available for migraines, but not all are backed by research and overuse of medication may be dangerous. Since most migraine symptoms are unique for each patient, it is important that healthcare providers help each individual based on what works for them. Below are treatments that have been traditionally used to treat all types of migraines in women.
NSAID Drugs: For immediate migraine relief, physicians may suggest over-the-counter non-steroidal anti-inflammatory (NSAID) pain medication such as acetaminophen or ibuprofen (Tylenol, Aleve, or Advil). These medications may be effective at short-term pain relief, but for more chronic or debilitating migraines, physicians may recommend triptans, such as Imitrex and Amerge, since NSAIDs have well-known adverse effects, such as gastric ulcers or kidney dysfunction.
Triptans: Triptans simulate serotonin, constrict blood vessels, and suppress overactive pain nerves that cause migraines. Triptans can be prescribed for migraines as pain relief, or as preventative medications. Some physicians may encourage women to take triptans a few days before the start of their period to reduce symptoms. However, while triptans may help with migraines, they also can have negative side effects such as high blood pressure, increased heart rate, nausea, and chest tightness. Since triptans constrict blood vessels, they should not be prescribed to anyone with a history of stroke or cardiovascular disease.
Natural Supplements: While there is no definitive conclusion about whether vitamin and mineral levels affect migraines, several studies have found that many people who have frequent migraines had lower levels of vitamin D, B2, Coenzyme Q10 (a nutrient that helps improve heart health and blood sugar regulation), and magnesium.[11,12] For example, scientists believe that a drop in magnesium levels can cause blood vessels to constrict and cause pain. However, all these studies are very recent and more research is needed before the evidence is clear. While these natural supplements may help migraines, it is important to know that supplements may contain harmful chemicals. Read more here.
Acupuncture: Acupuncture may help decrease the frequency and severity of migraines. Acupuncture is a traditional Chinese medicine technique where a specialist places small needles in specific “pressure points” on your back or neck to promote blood flow and reduce pain. A research paper combining the results of 22 separate studies (including a total of nearly 5,000 participants) found that acupuncture helped decrease the frequency and intensity of migraines and was similarly effective to traditional triptan drug treatment for preventing migraines. This suggests that acupuncture can be a safe and effective alternative to traditional drugs.
Hormonal Birth Control: Typically, hormonal contraceptives include estrogen or progesterone, or a combination of hormones. One cycle of birth control pills usually contains 21 “active” pills that contain hormones, and 7 “placebo” pills that do not contain hormones. During the week of placebo pills, a woman’s body experiences estrogen withdrawal. That drop of estrogen causes the endometrium (the lining of the uterus) to shed, resulting in a period. However, during that time of estrogen withdrawal, migraines may be more frequent as the body adjusts to the change in estrogen levels.
Some women taking hormonal birth control choose to skip the placebo week and start a new active pack right away. Continuous cycles of active estrogen-containing birth control pills have been found to shorten and decrease the frequency of periods and also to reduce migraines. However, when researchers studied whether continuous cycles of progesterone-only birth control reduced migraines, they found no effect.[14,15]
It is important to remember that hormonal birth control can affect people differently, and there are risks. Many physicians will not prescribe estrogen-containing birth control for women with migraines with aura due to an increased risk of stroke.
The United States Centers for Disease Control and Prevention (CDC) says it is safe for women with chronic migraines to use the following forms of contraception:
- Intrauterine device (IUD) (both hormonal and copper)
- Birth Control Implant (Nexplanon)
- Progestin-only shot
- Progesterone-only pills
- Any form of emergency contraception
No contraception restrictions exist for people with non-migraine headaches, but some birth control options are safer than others, and safety is also influenced by age, smoking, and other factors. Learn more about different types of medical contraception here, and the safety of different types of hormonal birth control pills here.
Hormone Replacement Therapy: To date, there are no FDA-approved estrogen hormone therapy treatments for migraines. Because of a suggested increased risk of stroke for women who suffer from migraine with aura, physicians and researchers recommend against the use of estrogen therapy for those women. However, many post-menopausal women whose migraines do not have aura take estrogen hormone supplements that are approved for treating the symptoms of menopause. This is called an “off-label use” because the hormones are not approved for migraines. Off-label use of any medication can be dangerous, but in this case it would be especially dangerous for women with a history of blood clots, stroke, or cardiovascular disease. A 2021 study found that women who had been on menopausal hormone therapy had a strong link between a history of migraines and increased chance of developing high blood pressure. Learn more about the risks and benefits of hormone therapy for menopause here.
Lifestyle Changes: While everyone has different symptoms and takes care of their migraines differently, some lifestyle choices may help reduce the frequency and intensity of migraines. Eating healthy foods, reducing stress, and having a consistent sleep schedule can help with migraine symptoms as well as promoting overall health.
The Bottom Line
Migraines are a type of headache that can result in throbbing, debilitating pain. They have been linked to fluctuations in levels of estrogen, a sex hormone affected by the menstrual cycle as well as menopause. Some of the treatments for migraines are unsafe for some people, especially those who have migraines with aura. Research is underway to better understand the causes and treatments for migraines, and one should always consult with your healthcare provider before trying any new treatments.
All articles are reviewed and approved by Dr. Diana Zuckerman and other senior staff.
The National Center for Health Research is a nonprofit, nonpartisan research, education and advocacy organization that analyzes and explains the latest medical research and speaks out on policies and programs. We do not accept funding from pharmaceutical companies or medical device manufacturers. Find out how you can support us here.
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