Headaches, migraine and hormones

Migraine is among the leading causes of years lived with disability worldwide and is routinely described by those who have it as a headache, which understates it considerably.

What migraine is

A neurological disorder involving altered brain excitability and activation of the trigeminovascular system.

Attacks typically last from hours to three days, with moderate to severe pain that is frequently one-sided and pulsating, worsened by movement, and accompanied by nausea and sensitivity to light and sound.

A minority experience aura — usually visual disturbance, sometimes sensory or speech symptoms — developing over minutes and lasting under an hour.

Attacks frequently have a prodrome the day before, with yawning, mood change, food cravings and neck stiffness, which is useful because treatment taken early works considerably better.

The hormonal connection

Substantial and clinically important.

Migraine is considerably more common in women after puberty, and the difference is largely accounted for by hormonal fluctuation.

Menstrual migraine occurs around the fall in oestrogen before menstruation, tends to be more severe, longer and less responsive to treatment than attacks at other times.

Migraine frequently improves in pregnancy, particularly after the first trimester, and frequently worsens during perimenopause because fluctuation is greatest then.

It often improves after menopause once levels are stable and low.

The contraception rule

The single most important safety point in this area.

Migraine with aura is associated with an increased risk of ischaemic stroke, and combined hormonal contraception increases that risk further.

Guidance in most countries therefore considers combined hormonal contraception contraindicated in women with migraine with aura.

Progestogen-only methods are generally acceptable.

Which means a new aura developing on combined contraception should prompt medical review promptly, and it is worth being explicit about aura symptoms when contraception is discussed, since the question is not always asked.

Triggers

Frequently overstated and worth examining individually.

The best-supported triggers are hormonal fluctuation, sleep disruption in either direction, missed meals, dehydration, stress and, notably, the letdown after stress rather than the stress itself.

Weather changes and bright or flickering light appear consistently.

Alcohol, particularly red wine, is reported commonly.

Food triggers are less reliable than folklore suggests, and there is evidence that craving specific foods is part of the prodrome — meaning the chocolate was a symptom rather than a cause, which reframes a great deal of dietary restriction.

A diary identifying personal patterns is more useful than a general list.

Treatment

Divided into acute and preventive.

Acute: simple analgesia and non-steroidal anti-inflammatories taken early and at adequate dose; triptans, which are migraine-specific and highly effective for many; anti-emetics, which help both nausea and absorption; and newer agents including gepants where available.

Taking treatment early in the attack is the most important practical factor.

Preventive treatment is considered where attacks are frequent or disabling: certain beta blockers, some antidepressants, some anti-epileptics, candesartan, and newer monoclonal antibodies targeting CGRP which have transformed treatment for people with frequent migraine.

Botulinum toxin for chronic migraine.

And for menstrual migraine specifically, short-term prophylaxis around the expected attack, or strategies that reduce the oestrogen fall.

Medication overuse headache

The trap that catches a large number of people.

Frequent use of acute painkillers — generally more than about ten to fifteen days a month depending on the drug — can produce a chronic daily headache that is caused by the treatment.

Codeine-containing and combination analgesics are particularly implicated.

It is diagnosed on the pattern and treated by withdrawal, which causes a period of worsening before improvement.

Anyone taking painkillers for headache most days should raise it, since the situation reliably worsens without intervention.

When a headache is not migraine

Features requiring urgent assessment.

Sudden severe headache reaching maximum intensity within seconds to a minute.

Headache with fever, neck stiffness, rash or confusion.

Headache with new neurological signs, weakness or visual loss.

New headache after the age of fifty, particularly with scalp tenderness or jaw pain on chewing.

Headache worsened by lying down, coughing or straining.

Headache after head injury.

Progressive worsening over weeks.

And headache in someone with cancer or immunosuppression.

None of these are typical migraine, and all warrant prompt medical attention.

General information only, not medical advice. Consult a qualified clinician about headaches, and seek urgent assessment for sudden severe headache or headache with neurological symptoms.