The World Health Organisation has identified migraine as one of the top 10 causes of years lost due to disability (1), showing the incredible impact this debilitating condition can have on many individuals – both male and female, old and young. However, migraine has been identified to affect three times as many women as men. The role of hormones, particularly in relation to menstruation, explains this increased prevalence.
How are hormones and migraines linked?
Migraine is affected by the hormonal environment in our body, and the changes in levels which can happen at different points in time. Significant changes in hormones are often seen in response to changes in our external environment, for example in response to stress. Similarly, hormone levels rise and fall during the natural cycles of female hormones seen in menstruation. It is these significant changes that can trigger migraine as the body struggles to respond to fluctuating hormone levels. Migraine suffers are often able to link their first experience with migraine, and changes in their migraine experience, to hormone-related time points such as puberty, pregnancy, and menopause.
What is a menstrual migraine?
Menstrual migraine typically describes an episode of migraine without aura which matches menstruation in both timing and frequency (2). These migraines most likely to occur in the two days leading up to a period, and the first three days of a period. Attacks of menstrual migraine are commonly more severe and last for longer than non-menstrual attacks. During a woman’s reproductive years, menstrual migraine has been found to affect 4-8% of women, and approximately 25% of migraine suffers (3), with estimates reaching up to 50% for women who find a direct link between menstruation and migraine severity (4).
Oestrogen plays the leading role in menstrual migraine; episodes occur in response to the female hormonal cycle. During menstrual periods oestrogen levels are high and consistent, however these levels significantly drop when the period ends. This process is often described as oestrogen ‘withdrawal’ and has been identified as a trigger for migraine attacks. This is suggested to be due to the increased sensitivity nerve cells experience to external triggers when oestrogen levels decrease (5).
When is menstrual migraine most severe?
Menstrual migraine is triggered during periods of hormone fluctuation, often starting at puberty. Prior to puberty, prevalence of migraine is equal between males and females, however leading up to and after puberty a significant increase is seen in females.
Another key period of hormonal change is menopause. The hormone environment can prepare for menopause years before end of menstruation – a period known as the perimenopause.
During this time oestrogen fluctuations are often the most unpredictable and significant (3), meaning many women experience severe and debilitating migraines from their late 30s until reaching menopause.
Menstrual migraine can also change with pregnancy. In early pregnancy the hormone environment is constantly fluctuating meaning some women may experience more severe migraine attacks. A pregnancy progresses migraine severity often improves, with studies showing up to 80% of pregnant women with migraine experience improvement in the second to third trimester (6).
For more information on pregnancy or menopause and migraine, read our factsheet.
What other factors can affect menstrual migraine, and how is it treated?
Contraceptives work to affect hormone levels meaning the type of contraceptive used can impact migraine severity and frequency. Some women find that their migraines are less severe while taking the contraceptive pill, however others report increases in severity especially in pill-free weeks where oestrogen levels significantly drop (7).
For more information on contraceptives and migraine, see the factsheet on our website.
If you suspect you suffer from menstrual migraine, keeping a migraine diary for at least three menstrual cycles can help confirm a hormonal link. Treatment options for menstrual migraine include the same as the recommended symptomatic relief for other migraine types. Trying to eliminate non-hormonal migraine triggers may help to reduce severity of an attack. Additional options may help to manage changes in the hormonal environment, including use of oestrogen supplements.
For more information on treatment for menstrual migraine, see the factsheet on our website.
Can hormonal migraines affect men?
Recent studies have provided evidence that similar changes in hormone levels may be an important contributor to migraine in men. Key changes in the male hormone environment identified include increases in oestradiol (8) and decreases in testosterone (9) in male migraine sufferers.
Where can I find more information?
Our Heads Up podcast episode on Hormones and Migraine is a great place to start, providing a wealth of information on hormonal migraines. In addition, further information can be found in our factsheets, available on the National Migraine Centre website.
(1) World Health Organization (2001). Mental Health: New Understanding, New Hope. Geneva: WHO
(2) Barra, M., Dahl, F.A., MacGregor, E.A. & Vetvik, K.G. (2019) Identifying menstrual migraine- improving the diagnostic criteria using a statistical method. [Online] 20 (1), 95. Available from: doi:10.1186/s10194-019-1035-7
(3) MacGregor, E.A. (2020) Menstrual and perimenopausal migraine: A narrative review. [Online] 142, 24–30. Available from: doi:10.1016/j.maturitas.2020.07.005
(4) Migraine Trust (n.d.) Menstruation. Available from: https://www.migrainetrust.org/about-migraine/trigger-factors/menstruation/
(5) MacGregor, E.A. (2009) Menstrual Migraine: Therapeutic Approaches. [Online] 2 (5), 327–336. Available from: doi:10.1177/1756285609335537
(6) Melhado, E., Maciel, J.A. & Guerreiro, C.A.M. (2005) Headaches during pregnancy in women with a prior history of menstrual headaches. [Online] 63 (4), 934–940. Available from: doi:10.1590/s0004-282×2005000600006
(7) National Health Service (n.d.) Hormone Headaches, Available from: https://www.nhs.uk/conditions/hormone-headaches/
(8) van Oosterhout, W.P.J., Schoonman, G.G., van Zwet, E.W., Dekkers, O.M., et al. (2018) Female sex hormones in men with migraine. [Online] 91 (4), e374–e381. Available from: doi:10.1212/WNL.0000000000005855
(9) Shields, L.B.E., Seifert, T., Shelton, B.J. & Plato, B.M. (2019) Testosterone levels in men with chronic migraine. [Online] 11 (2). Available from: doi:10.4081/ni.2019.8079