When I ask women in clinic what they think are their potential triggers approximately 75% say, “hormones” and they often open consultations with the phrase:
“I definitely have menstrual migraine”.
The majority however, do not. Changes in hormone levels are a potent trigger for migraine attacks but only less 10% of suffers are classified as having “menstrual migraine”. This can mean that any woman who suffers with migraine has the potential to have an attack around menstruation or at other points in the cycle where hormone levels fluctuate. This can explain why puberty and the peri-menopausal phases can be times where women experience increasing numbers of attacks.
The menstrual cycle is ruled by a complex of hormones which include oestrogen and progesterone as well as other substances which continuously form a feedback loop between the brain (pituitary anad hypothalamus glands) and the reproductive organs. The cycle essentially exists to ensure the body is ready for pregnancy to occur:
- At the beginning of the cycle the oestrogen levels begin to rise causing the the lining of the womb to build up as egg development is stimulated in the ovary and subsequently released (ovulation).
- In the second half of the cycle, the progestogen levels start to rise to ensure the lining stays thick in order to receive the fertilised egg for implantation and embryo development.
- If fertilisation does not occur, the egg is reabsorbed and the oestrogen and progesterone levels begin to fall prior to menstruation.
What are menstrual migraines?
Menstrual migraines are typically migraine without aura that occurs only during the phase of menstruation (that is between two days before a period and in the first three days). This type of migraine can be more prolonged than other forms.
These are thought to be triggered by the drop in oestrogen levels which occurs approximately 48 hours before menstruation or due to the release of a substance called prostaglandin during early menstruation.
The only way to establish whether or not this type of migraine occurs is to keep a migraine diary and tracking it with your periods.
Can hormones still trigger attacks if this isn’t the case?
As I’ve said, many women who suffer with migraine attacks find they are hormonally sensitive and so more likely to have attacks at some point around their period. For the sake of semantics these migraine attacks are “menstrually associated migraine”. People often find that they have more attacks during phases where they have a sudden surge of hormones such as puberty, pregnancy, breast feeding and around the menopause.
How can these be treated?
This depends on whether you purely have menstrual migraine or if you have menstrually associated migraine and what stage of life you are at. Options include:
- Hormonal control which can be further divided into:
- The Pill. This can be an option for people with any type of hormonally sensitive migraine (although it is worth noting that the oestrogen component of the combined pill can make some people suffer more frequent attacks). With menstrual migraine some people benefit from “tricycling” there pill where they take it almost continually. Others find benefit from stabilising their hormone levels with the progestogen only pill.
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- Oestrogen. In menstrual migraine some people can benefit from supplementing their falling levels with oestrogen applied by patch or gel for a week around their period.
- HRT can be beneficial in the perimenopause but I will discuss this in more detail in another article…
- Mefanamic acid. People who have heavy painful periods may be familiar with this medication: it is in the same family of medications as ibuprofen (NSAIDs) and is thought to help in menstrual migraine by reducing the prostaglandin release which may contribute to menstrual migraine in some cases.
- Frovatriptan. This is a long-acting triptan which can be used on a regular basis around the expected migraine time to prevent attacks. Although we usually advise against using triptans on a regular basis, taking Frovatriptan twice a day from two days before the expected attack for 6 days seems to help with menstrual migraine in some cases.
- Preventative. Any formal preventative has the capacity to help with menstrually associated migraine and severe menstrual migraine.
Are there any natural ways of managing this?
Hopefully that’s given a brief overview about hormonal migraine. Like with all types of migraine there is no “one size fits all” answer and most people have very individual and varying triggers, one of which is often hormones. I will discuss migraine in pregnancy and perimenopausal migraine in more detail later on…