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Estrogen fluctuations and migraines: The menstrual connection

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Most migraines in women are linked to menstruation.  The pattern of how these migraines occur helps guide prevention and treatment choices.

Migraines are all too common. And unfortunately, they’re even more common in women. About 1 in 5 women experiences migraines, compared to 1 in 16 men.

One possible reason for this? Different hormones.

“In childhood before females go through their first period (menarche), the rate of migraine is pretty similar between boys and girls,” says Juliana H. VanderPluym, M.D., a Mayo Clinic neurologist. “After puberty, it shifts, and the rate becomes higher in teenage girls and stays that way throughout life.”

The specific hormonal culprit seems to be estrogen — but it’s not simply a matter of how much estrogen is in your system. Rather, it’s the changes in estrogen levels, Dr. VanderPluym says. These fluctuations can happen under a variety of circumstances: with menopause and pregnancy, when taking oral contraceptives, and during every menstrual cycle.

In fact, about 60% to 70% of women who get migraines experience menstrual migraines. There are two types of menstrual migraine:

  • Pure menstrual migraines: Women experience migraines only right before or during their periods
  • Menstrually related migraines: Women experience migraines right before or during their periods but also experience migraines outside of that time frame.

It might seem like having menstrual migraines would be more convenient than nonmenstrual migraines; after all, those with regular periods can predict when they’re coming. But they may actually cause more pain, Dr. VanderPluym says. “They can also be more treatment resistant, meaning treatments just don’t work on them as well.”

The good news: In addition to the plethora of treatment options for migraines — including nonprescription and prescription rescue medications, and nonspecific (antidepressant, blood pressure and anti-seizure drugs and Botox) and specific (calcitonin gene-related peptide, or CGRP blocking) preventive treatments — there are additional treatments you can try for menstrual migraine.

Bridging over a predictable migraine cycle

Generally speaking, migraine treatments fall into two categories: acute treatments and preventive treatments.

You take acute treatments (also known as rescue treatments) when you are experiencing a migraine and looking for relief. Nonprescription pain relievers such as ibuprofen (Advil, Motrin IB, others) and a class of prescription drugs called triptans — sumatriptan (Imitrex), rizatriptan (Maxalt) and others — are examples of acute treatment.

Preventive medications are taken regularly to try to reduce the frequency and severity of your migraine attacks before they happen. Some antidepressants and blood pressure lowering medications are used for this purpose, as well as a newer type of migraine-specific preventive known as CGRP monoclonal antibodies.

For those with menstrual migraine, there’s a third type of treatment: bridge therapy, also known as mini prophylaxis.

Your doctor may recommend this if you have a regular menstrual cycle and can predict when you’re likely to get a migraine. In bridge therapy, you take medication for several days before and during the time of your expected migraine, in an attempt to prevent or mitigate attacks.

Examples of medications used this way are triptans and nonsteroidal anti-inflammatory drugs (NSAIDs) such as naproxen sodium (Aleve).

Tackling the less predictable patterns

 But what if you don’t have a regular cycle and you have menstrually related migraines, so not all your migraines are predictable? What if bridge therapy isn’t enough, and you’re still getting headaches?

It’s not a good idea for anyone with migraine to take acute medications too frequently, or you can experience medication-overuse headaches.

For some women with menstrual migraine, there may be another option: taking combined hormonal contraceptives, which contain both estrogen and progestin. Birth control pills are common, but other delivery systems — including vaginal rings (NuvaRing, Annovera) — can be considered.

“Combined oral contraceptive pills can be helpful to basically stabilize the hormonal levels so there aren’t those fluctuations that are maybe the triggering factor for you,” Dr. VanderPluym says.

Your doctor may instruct you to take these pills or use the rings continuously (with no break) or on an extended regimen (so that you only bleed a few times a year) to minimize the number of times you experience hormone fluctuations.

Dr. VanderPluym says it’s a good idea to involve your primary care provider, a women’s health specialist or your gynecologist in your decision to use birth control.

“Is this just for migraine? Or is this for cycle regulation? Maybe it’s also for birth control, or for treating conditions like endometriosis,” she says. “As a neurologist treating these conditions, I’m focusing on the headaches, but we need to think of how the medication affects the whole person.”

One important caveat: Combined hormonal contraception is not generally advised for women who experience migraine with aura, due to an increased stroke risk. An aura can include visual disturbances, such as flashes of light or blind spots, or other disturbances, such as tingling on one side of the face or in an arm or leg and difficulty speaking.

Putting it all together

Of course, women with menstrual migraines don’t have to stick with just contraceptives and bridge therapy — other general migraine treatments may be helpful as well.

“It’s always a matter of really looking at the overall migraine burden that someone experiences and picking out the characteristics that we need to highlight in their treatment,” Dr. VanderPluym says. “So if it’s frequent, we should be considering prevention. If there’s a menstrually related component, do we want to be considering a hormonal therapy as long as they don’t have aura? And if it’s purely menstrual related, then maybe just the mini prophylaxis, or bridge therapy, will suffice, but that isn’t always the case.”

If you’re experiencing menstrual migraines without adequate relief, talk to your primary care doctor or a neurologist to discuss your options.

Juliana H. VanderPluym, MD, FRCPC

Dr. VanderPluym is an Assistant Professor and Consultant in the Department of Neurology within the Division of Headache at the Mayo Clinic Arizona. She received her Doctor of Medicine with Special training in Research from the University of Alberta, Edmonton, Alberta, Canada and also completed her residency training in Pediatric Neurology at the University of Alberta. She is a fellow of the American Headache Society.

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