Migraine headaches disproportionately affect women. According to the American Migraine Foundation, females experience more symptoms, and the migraine lasts longer than it does in men with the issue. Women experience migraines at a rate 3x higher than their male counterparts. Prepubescent rates of migraines are similar in both boys and girls, but after puberty, something changes. What changes, you may ask? Hormonal fluctuations begin in puberty, and it is these hormonal fluctuations that researchers have found to be tied to the development of migraine headaches. Peak migraine prevalence occurs in women who are in their childbearing years.

Hormonal migraine development is tied to the menstrual cycle. Most women with hormonal migraines notice them at the beginning of their cycle – 2 to 3 days after they begin menstruation. Researchers believe that fluctuating levels of estrogen (especially a precipitous drop just prior to menstruation) is tied to the development of the migraine attack. The magnitude of the decrease is thought to be more important to the pathophysiology of the migraine than having simply “low estrogen”. It is interesting to note that during pregnancy, when estrogen levels are at their highest, migraines improve for most women.

The most common treatments for hormonal migraines are to use the NSAID drugs for prevention a few days prior to your period, and continue up to 2 weeks after your period (Mayo Clinic). This of course is for women who have a regular, predictable menstrual cycle. If you are perimenopausal or have an irregular cycle, your doctor may want you to take preventative medications every day, depending on the severity of the migraine. Hormonal contraceptive pills and devices can help some women, but they make the headaches worse in others. Anecdotally, we have seen women have marked improvement with their migraines when beginning bio-identical hormone replacement therapy (BHRT). Dosage forms that provide a slow release of estrogen into the body will have less likelihood of aggravating migraine symptoms. The best example of one of these dosage forms is a transdermal cream, or a conservatively dosed implanted pellet. Dosage forms that cause levels to spike quickly, such as buccal troches, tablet triturates, and injections, may aggravate the migraine rather than help.