Hormonal Influences on Headache

Reference work entry


Specific hormonal events during the reproductive years have a profound influence on migraine in women. Onset of migraine is usually postmenarche, during the teens, and early 20s. Migraine prevalence peaks during the early 40s and improves postmenopause. During the reproductive years, migraine is three times more prevalent in women than in men. This is generally considered to be the result of female sex hormones on migraine. Menstruation is a significant migraine trigger with more than 50% of women reporting an association. Attacks are most likely to occur during the 2 days before menstruation and the first 3 days of bleeding. Menstrual attacks are almost invariably without aura, even in women who have attacks with aura at other times of the cycle. The majority of attacks can be controlled with symptomatic treatment alone. However, since they are more severe, of longer duration, and more disabling than non-menstrual attacks, targeted prophylaxis may be necessary. Recognition of menstrual migraine as a specific entity has resulted in improved diagnosis and increased research into the condition. However, our understanding of the pathophysiology and the consequent development of effective management strategies remain limited. Clinical and research data support an association between attacks of migraine without aura and “withdrawal” of endogenous or exogenous estrogen, following a period of estrogen priming. Estrogen “withdrawal” migraine can be prevented by maintaining constant levels of estrogen, with or without suppression of the natural menstrual cycle. Further research is necessary to identify if estrogen “withdrawal” is a primary or secondary mechanism. Other mechanisms have also been implicated, particularly prostaglandin release as occurs during migraine associated with dysmenorrhea. Perimenstrual prophylaxis with triptans has shown efficacy. Limited research suggests that high levels of estrogen, such as that occur during pregnancy, with use of combined hormonal contraceptives, and with estrogen replacement therapy, can trigger migraine with aura. The pathophysiology of this effect is poorly understood. Genetic susceptibility is a recognized factor in the development of both migraine with and without aura and research for genes involved in hormonal pathways is ongoing.


Menstrual Cycle Migraine With Aura International Headache Society Migraine Without Aura Menstrual Migraine 
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© Lifting The Burden 2011

Authors and Affiliations

  1. 1.The City of London Migraine ClinicLondonUK
  2. 2.Regionales Schmerzzentrum EssenEssenGermany

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