Headache, health

Hormonal migraines

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 hormones

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.

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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. 

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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.  

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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…

Headache

Migraine Triggers

In my post on acute treatment I discussed preventing migraine attacks by identifying triggers.  Triggers can be internal or external and are essentially any change or event which causes a migraine to occur.

How do triggers cause migraine?

Every individual who suffers with migraine will have a “threshold”.  I like to think of this as a line: anything which pushes you over the line will cause a migraine, and the factors which push you over the line are your triggers.  These triggers tend to be multiple and work together but some will be stronger or more potent than others.

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Migraine Triggers National Migraine Centre

How can I spot my triggers?

There are a few useful facts about migraine that are instrumental in identifying triggers:

  1. Migraine takes 12-24 hours to develop, which is much longer than most people suspect
  2. Different people have different triggers what causes migraine in one individual may not in another
  3. Migraine thresholds vary. That line I discussed above can move up or down at different points in your life: this can make “new triggers” appear if your line is particularly low as you are more susceptible to its effects than before.

What sorts of things act as triggers?

As I have said, triggers vary greatly from person to person but there are a few themes that are common to most people who suffer with migraine and I will list some examples:

  • Diet: You just have to enter the word migraine into a search engine and lots of posts about specific food triggers like cheese, chocolate and citrus will come up.  Although specific triggers do exist, these have largely been disregarded by headache professionals.  Historically, when people have tracked their migraine they have identified that they would ingest cheese, chocolate etc two hours before attacks: these must be triggers right?  Unfortunately not.  They are now thought to be cravings brought on by a drop in blood sugar level before the migraine starts.  However, rapid changes in blood sugar level can act as a migraine trigger so I advise people to avoid fast-burning carbohydrates (i.e. very sugary foods) where possible and concentrate on a high-protein diet eating slow burning (i.e. brown rice, brown pasta etc) carbohydrates where possible.  People should also avoid skipping meals and consider adding in healthy snacks during the day and before bed-time to prevent their blood sugars from fluctuating to often.

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    • Sleep:  changes in sleep pattern are another common trigger.  Many people identify lack of sleep as a trigger but do not always think about their sleep routine: shifts in this normal pattern of even up to an hour each way can precipitate a migraine.  An example of this is a weekend where someone may have stayed up an hour later on the Friday night or treated themselves to a lie-in on the Saturday morning.  This can be one of the factors that results in a weekend migraine.  It can also be a particular problem for shift-workers as I certainly found when rotating through my hospital jobs.
    • Stress: this emotion does get implicated in a lot of medical and psychological problems but it certainly has a role in migraine.  Often it is noted that the migraine occurs when the stress has been alleviated (i.e. when people relax).  However, other emotions can trigger migraine too: anger, excitement, sorrow, joy… this can be particularly evident in children who often have attacks when they’re excited about events such as birthday parties or trips out.

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  • Hormones:  a study at the National Migraine Centre showed that 50% of women were more likely to suffer a migraine attack at the time of their period.  Menstrual migraines exclusively occur during a woman’s period but most women have attacks at other times of the month too which means this is one of their triggers but not the entire cause.  Some women who are sensitive to hormonal changes benefit from regulation of their cycle with the contraceptive pill or coil, unfortunately this can exacerbate symptoms in others.  Women who are hormonally sensitive may find their migraine attacks are much worse around the menopause and thus can benefit from HRT.
  • Neck and back pain: any type of muscular or joint pain in the neck and back can exacerbate migraine.  This can be as simple as poor posture or a muscular injury.  This can be improved with gentle exercises, physiotherapy or osteopathy.
  • Light sensitivity: although this can sometimes be a prodrome rather than a trigger, some people are light sensitive between migraine attacks and this can contribute towards causing further migraines.  Computers or VDUs can be a source of this and it is the blue-green wavelengths emitted which are troublesome.  There are programmes available which act as a screen filter and some people benefit from tinted lenses on their glasses.  Taking frequent breaks from looking at a screen is also important.

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Why should I bother?

Most people who have migraine do not want to take medication, and taking too much can lead to problems such as medication overuse headache.  If you can identify your triggers and try to eliminate them through life-style measures you can reduce the number of attacks you have (some studies show by 50%!).  The way to identify these triggers is to keep a diary.

For more information see:

The Migraine Trust – Triggers

The National Migraine Centre Factsheet

Headache

Treating Migraines (acute treatment)

So you’ve established you suffer with migraine.  So what do you do?  As I’ve said before, I didn’t used to do much to help myself.  I’d take the wrong pain-killers and suffer through my day and I know, from my job as a headache specialist, countless others do the same.

Treatment is divided into two types: acute (immediate) treatment and preventative treatment.

This is to get rid of the symptoms you experience during a migraine.  The easiest way to work out what to take is to know why your taking it:

1.  Domperidone (anti-sickness or pro kinetic medication)

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The first medicine I advise to take is Domperidone and it helps with nausea and vomiting.  This occurs because the stomach is directly affected by the migraine process: it stops emptying in a process called gastric paresis.  This means anything sitting in the stomach cannot move forward into the part of the gut where it will be absorbed.  This happens in all migraine regardless of whether or not people feel queasy.  Gastric paresis also means that any medicines taken won’t be absorbed properly.  The main function of Domperidone is get the stomach to empty (termed pro-kinesis) and this helps any pain-killer to work better.

2.  Soluble Aspirin

The next medication is a good old fashioned pain-killer: Aspirin.  This has largely fallen out of favour as a analgesic for most conditions but it works well for migraine and headache.  Because the gut has slowed down it is best to take this in the soluble form so it is better absorbed.  Better still, it should be dissolved in a sugary, fizzy drink.  The fizz helps improve the absorption of the aspirin.  The sugar helps to reverse a drop in blood sugar that occurs before the migraine starts (often making people crave sweet or salty food such as cheese or chocolate… more on this in the article about triggers).

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Other non-steroidal anti-inflammatories (NSAIDs) such as Ibuprofen or Naproxen can be used at high dose if this does not help. This is not a suitable medication if you suffer with gastritis or for some asthmatics so I would advise speaking to your GP if this applies to you.

3.  Triptans

If the migraine is severe or if the symptoms don’t improve 45 minutes after steps one and two have been take a Triptan should be tried.  This class of medicine are specific painkillers developed for the treatment of migraine and headache.  There are 7 of them on the market and treatment usually starts with the first one that was developed: Sumatriptan (Imigran) which is available over the counter.

Some people find they can have side-effects (usually drowsiness or nausea) with this medication or it is not effective.  It can be tried in higher doses via the GP or taken via a different route if it does not work fast enough (a nasal spray and self-injection are available).  If it is not suitable, one of the other 6 triptans can be tried.

Is there a limit to how often I can take pain-killers?

In a word: yes.  Unfortunately, if you suffer with migraine you can develop a problem called Medication Overuse Headache.  It’s a strange phenomenon which seems only to affect people who suffer with headache disorders, most commonly migraine.  It happens if you take too many painkillers in a month for 3 consecutive months and causes a more severe headache or worsening of migraine features.  As a guide it occurs if:

  • NSAID medications such as ibuprofen, naproxen or aspirin and other simple pain-killers such as paracetamol are taken on more that 14 days a month
  • Triptans are taken on more than 8 days a month
  • Codeine and other opioids are taken on more than 6 days a month.

If you think this may be a possibility, I would advise speaking to your GP about how to detox from painkillers and consider whether a preventative medication may be suitable.

Are there any medications I should avoid?

Yes. There are some strong pain-killers which are not suitable for the treatment of migraine.  The advice of most headache specialists is that patients who suffer with migraine should avoid codeine and other morphine-type medication (opioids).  They are not particularly helpful in getting rid of migraine symptoms and often worsen the gastric slowing I described earlier.  They also are prone to cause rebound-headaches.  They are often prescribed by doctors due to the fact that migraine can be very painful but they should be avoided at all cost where possible.

What can I do to stop getting migraines?

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Most people don’t like taking medications.  This is where migraine prevention comes in.  The most effective way to stop having migraine is to identify what your triggers are.  These are different in everyone but I have written an article to help identify them.  Again, keeping a diary is key to identifying what your triggers are.

If you find you are suffering with migraines more than 4 times a month, or if they are so severe they are stopping you from effectively carrying out your daily life, it is worth considering preventative treatment.