Since the beginning of time, women’s hormones have been wreaking havoc and causing migraines in women. Of course, men have hormones and can get migraines too, but women are almost 5x more likely to have migraines than men. Why? One word. Estrogen. And more specifically, the changing levels of estrogen in women.
There are several times in a woman’s life when migraines might first appear or become worse, and they are all linked to changing levels of hormones. Children can have migraines too. And in fact, boys and girls have migraines in about equal amounts. But when puberty occurs, migraines in girls take off at about 7:1 as compared to boys. And women may continue having interval worsening and changing of migraine during life changes when hormones are known to fluctuate dramatically.
Menstrual migraine is actually a different migraine than a woman’s typical episodic or chronic migraine, and is specifically linked to estrogen withdrawal. A menstrual migraine is defined as occurring one to two days prior to the onset of menses and lasting about 2-3 days after the onset of menses. It is linked to the abrupt drop in estrogen that occurs just before the onset of menses. And by definition, it must occur with at least 2/3 of periods and not be associated with aura, even if a woman gets an aura with her other migraines.
These migraines tend to be more severe than other migraines and be harder to control with normal migraine medications. There are several strategies that can be used to control these migraines.
If you only have menstrual migraines without many other migraines, then you might want to just try control these without taking daily prophylactic medications. If you have just been trying to abort these migraines after onset, it may be difficult to get control of them after the fact. You may need to start taking a medication BEFORE the onset of these migraines. For these strategies you do need to have regular menstrual cycles and be able to predict the onset of menses.
One strategy is to take naproxen twice daily starting about 5 days prior to the onset of menses and then continuing for about 5 days after onset. Some women feel a significant improvement with this method.
Another method would be to take a longer acting triptan (abortive migraine medicine) such as frovatriptan. You would start taking this medication twice daily for 2 days prior to onset of menses and for about 2-3 days after onset. Most people have a hard time obtaining enough triptans and they can be expensive making this a more difficult strategy to use.
Perhaps the best strategy, especially if you are desiring contraception also, would be to take a combined oral contraceptive pill with a low dose of estrogen. You would need to take this pill continuously, skipping the placebo week, to keep your estrogen levels up to prevent menstrual migraine. This works very well for some people, but there are those women who cannot tolerate any form of estrogen at all or women with migraine with aura for whom estrogen supplementation is generally contraindicated. These women may need to try a form of contraceptive without estrogen.
An example would be the depo provera shot which is only progesterone. Another option would be a progesterone only pill. The benefit of these, is that they stop your ovaries from cycling and ovulating which often gives women significant relief from migraine. Some women may have increased headache or weight gain with this strategy, so you may have to try several options to find one that works for you.
Will my migraines get worse during pregnancy?
Another time when migraines tend to act up is during the child bearing years. One problem may be that a woman who is planning a pregnancy may need to stop her daily prophylactic medication. If you have very refractory migraines, you may wish to continue your prophylactic medication at least until after your first trimester when migraines tend to be their worst. There are some prophylactic medications which are relatively safe in the first trimester such as beta blockers or some antidepressants, while others such as anti seizure medications are not. Talk to your doctor to see if remaining on your medication for a while is a safe possibility.
During the first trimester of pregnancy estrogen and progesterone begin to rise rapidly. Again, it is this change of hormone levels that is truly the trigger of migraines and not the absolute level. This can be a very difficult time for women. I know that I personally had a very difficult time with my pregnancies and was always seeking things that I could take for migraine safely.
There are several supplements that are safe during pregnancy including magnesium, B2 riboflavin, feverfew and butterbur. Taking these, especially in the first trimester, may lessen your migraine symptoms.
Taking triptans in pregnancy is a very controversial subject. Generally, in the United States this is a firm no. However, most other countries have used large studies of retrospective data to prove that these medications are likely very safe in pregnancy. The UK for instance, uses triptans in pregnancy and believes that they are safe. I too had to use them during pregnancy, as not taking anything for migraine was just not an acceptable solution. The point is, there are some things that you can take if needed. Talk to you doctor to find a strategy that works for you.
Luckily, once women get into their second trimester, migraines tend to generally improve. This is because now both of your hormone levels of estrogen and progesterone are very high and stay this way throughout the remainder of pregnancy. This tends to be the time that most migraine sufferers have some reprieve from their symptoms.
After delivery of your baby, your hormones drop very quickly to a very low level, triggering post partum depression and migraines. One thing that is important to know is that triptans have been deemed very safe while breast feeding and do not need to be avoided. Using high doses of ibuprofen or naproxen are generally safe during breast feeding as well. Furthermore, the supplements we talked about above, are also safe during breastfeeding. Additionally, most of the prophylactic drugs used to prevent migraine are also safe during this time. If your post partum depression lingers for more than a few months, talk to a hormone specialist to see if you need some hormone supplementation during this difficult time.
What about Peri menopause and Menopause?
While menopause symptoms have been the butt of many jokes, I can assure you that when your hormones start fluctuating in peri menopause, it is anything but a laughing matter. For many women, entering into your 40’s and starting peri menopause will be some of the most difficult years of your life. Not only are all of your hormones dropping including estrogen, progesterone and testosterone, estrogen levels can also swing rapidly from one month to the next. One month being sky high and showing estrogen dominance, while the next month estrogen drops very low. This type of hormone changing can really wreak havoc causing depression, anxiety, early morning insomnia, fatigue, weight gain especially around the abdomen, and difficult to control migraines.
Hormone supplementation is very important during this time. Not only is hormone supplementation important for cardiovascular health, bone health and overall mental and physical well being, it will likely also improve your migraine symptoms. Unfortunately, most traditional allopathic physicians truly know very little about treating hormone abnormalities. You will likely need to seek out an integrative doctor or hormone specialist to help you. I can attest from personal experience that getting my hormones tested and treated truly saved me.
After the birth of my first child, I had severe depression, fatigue, intractable migraines and infertility. After years of infertility treatments, a hormone specialist identified that I had no detectable testosterone and replaced it with supplementation. Not only did I feel great and have resolution of my migraines, I got pregnant naturally right after that. Years later, I found out that I had estrogen dominance as I entered into peri menopause, with sky high estrogen levels causing weight gain and migraine, also a big risk for various cancers including breast cancer. With help from a hormone specialist, I was able to bring those levels down to a healthy level.
Generally, once you are firmly in menopause, your hormone levels remain very low and migraine is often either resolved or significantly improved.
The take away is that hormones, and the changing levels of hormones, are big factors in women’s migraines and overall health and well being. If you are suffering from migraines or mood swings, infertility, insomnia, fatigue or many other symptoms, consider finding a hormone specialist to assist you in finding out if hormone supplementation may help you.
If you are in the Southern California area, you can contact me. I do house calls.
To your health,
Dr. Camille, M.D.
The Migraine Doctor