Andrea Landau, a 33-year-old migraine sufferer from New York City, has been getting migraines since she hit puberty. Over the years, many of her worst migraines have occurred in the days leading up to her period.
“I used to have to leave work because they were so intense,” Landau says.
This story is not uncommon. Women are three times more likely to get migraines than men, and more than half of the migraines women suffer are triggered by changes in estrogen levels. In a recent poll of migraine sufferers on the National Headache Foundation’s Facebook page, 82 percent of respondents said they are “much more likely” to get migraines before, during or immediately after their period than at any other time of the month (see sidebar).
“Hormone fluctuation is a huge trigger that makes women more vulnerable to migraines,” says Sheena Aurora, MD, director at Swedish Headache Center in Seattle.
Causes of Menstrual Migraine
Roughly 75 percent of migraine sufferers are women. Among women with migraines, about 60 percent experience menstrual-related migraines, says Susan Broner, MD, a neurologist and headache specialist at The Headache Institute of New York and assistant clinical professor of neurology at Columbia Presbyterian Hospital. Fluctuations in estrogen are the primary culprit, creating a maelstrom of physiological changes that trigger intense and long-lasting migraines.
“The drop in estrogen lowers the pain threshold, enhances nerve excitement and causes nerve inflammation,” Dr. Broner says. It also impacts levels of serotonin and dopamine. “Together, it leads to migraines that cause greater functional impairment.”
These migraines commonly occur during menstruation, but also can be triggered by ovulation in the middle of the menstrual cycle when estrogen levels rise slightly and then drop, says Jan Lewis Brandes, MD, director of the Nashville Neuroscience Group at St. Thomas Health Services and assistant clinical professor of neurology at Vanderbilt University.
“It’s not so much the drop itself as it is the fluctuation,” she says. “It acts as a primer for the migraine.”
Proactive Treatments for Menstrual Migraine
Hormonally influenced migraines tend to be more intense and longer lasting than other migraines, Dr. Broner says. To make matters worse, the acute treatments that work for everyday migraines, such as triptans and anti-inflammatories, may not be as effective for hormonally related headaches.
But there is some good news. Because menstrual migraines are often predictable, they can generally be managed with a little advance planning.
Physicians recommend women avoid stacking triggers—for example, combining red wine and chocolate—in the days leading up to their period. Sufferers should also keep a diary of their migraines that includes when the attacks occur in relation to their menstrual cycle. This is particularly useful with menstrual migraines because many women find that by taking proactive measures (i.e., ingesting medication before a menstrual migraine starts), they can head off migraines and/or reduce their severity.
Estrogen drops two to five days before menstruation begins, and that is part of a cascade of events that triggers menstrual migraine. To combat this painful condition, doctors may prescribe mini-prophylaxis or mini-preventive treatments, in which patients begin taking triptans and anti-inflammatories two days before their menstrual migraine begins and for the five to seven days after.
“In many cases, this causes the migraines not to come at all or to be far less intense,” Dr. Broner says.
This has been the case for Landau, who began working with Dr. Broner five years ago to identify her migraine triggers and create a custom treatment plan, which now includes preventive medication around her period and not combining other migraine triggers during her most vulnerable days.
“It has changed my life,” Landau says. “I still get [menstrual migraines], but they are a lot less intense now that I have the right combination of medications.”
Treatment for Menstrual Migraine
Unfortunately, no one treatment method meets the needs of every sufferer or every headache, and the obvious solutions aren’t always effective, Dr. Brandes says.
“The temptation with menstrual migraines is to want to simplify management of the hormonal influence,” she says.
That might mean going on continuous birth control pills to prevent periods, or using an estrogen patch or other hormone therapies to blunt the hormonal fluctuation.
But such treatments don’t work for everyone, according to Dr. Brandes. Many women who are on the pill suffer breakthrough bleeding or continuous bleeding that is triggered by hormone fluctuations, and this can lead to more migraines. Other women are not good candidates for estrogen replacement therapy due to a high risk for cancer or cardiovascular disease.
Instead of assuming a one-size-fits-all approach, doctors must work collaboratively with patients to understand their health risks and headache history. Once this record is established, they can try different combinations of medications and track the results.
“The often-missed hormonal influence on migraine is why it is so important to keep a headache and menstrual diary and for doctors to take a headache history that includes the hormonal influence,” Dr. Brandes says.
For women who suffer from menstrual migraines, that history should include when the migraines start in relation to their first period, when during the month the migraines most frequently occur in relation to ovulation and menstruation, and whether the headaches get better or worse as a result of using birth control pills or getting pregnant.
“If I know that the oral contraceptive pills made your migraines worse in your 20s, I would be more reluctant to prescribe them as a solution in your 40s,” Dr. Brandes says. “Knowing your hormonal history increases the chances that the treatment we choose will be a success.”
Pregnancy, Menopause and Menstrual Migraine
Women who suffer from hormonally triggered migraines often worry about how they will manage their headaches during periods of hormonal change, such as pregnancy and menopause. During pregnancy, when medical treatment options are limited, this is a valid concern, says Susan Broner, MD, of The Headache Institute of New York.
“The first trimester can be difficult,” Dr. Broner says.
Lack of sleep, changes in eating habits and hormonal fluctuations can cause the migraines to temporarily increase. But according to Dr. Broner, studies show that toward the end of the first trimester, more than half of women report improvements in their migraines. By the second trimester, more than 80 percent report improvements that last through the pregnancy.
For women who experience migraines and are planning pregnancy, Dr. Broner suggests implementing lifestyle changes—including regulating sleep patterns and meals, staying hydrated and weaning from caffeine—before getting pregnant.
“Caffeine can be a great tool to turn off a headache, but only if your body isn’t used to a daily dose of it,” she says. “Frequent use of caffeine should be avoided as that can cause more headaches.”
In some lucky cases, women report that pregnancy can cause their migraines to essentially disappear, as was the case with Andrea Landau’s mother. The younger Landau has suffered from migraines since she was a teen—a trait she inherited from her mother.
“My mother always had migraines before I was born, but after she was pregnant with me, they pretty much stopped,” she reports. “Now she gets them maybe once a year.”
For other women, entering menopause can cause their migraines to stop altogether.
However, during the years leading up to menopause, when the ovaries gradually begin to produce less estrogen and hormone levels tend to fluctuate more widely, migraines can get a great deal worse.
“Some women who haven’t experienced migraines since their 20s find they return with a vengeance during perimenopause,” Dr. Broner says. “Perimenopausal women in their 30s and 40s experience a lot of hormone fluctuations along with insomnia, hot flashes and irregular periods. And all of these changes can lead to more frequent migraines.”
This can be a difficult time, but Dr. Broner urges women to remember that for many there is a light at the end of the tunnel.
“Once the hormone fluctuation stops and menopause begins,” she says, “most women tend to see improvements.”