Migraines affect 1 in 5 women, with three times as many women being affected as men. The symptoms can be really debilitating and include much more than headaches.

Triggers

There is often a history of migraine in the family, suggesting a genetic susceptibility.

It can be helpful to look at whether there are triggers for an attack, sometimes it’s a combination of these triggers rather than one alone. Common ones include lack of sleep, increased stress, missed meals, alcohol, caffeine, and weather changes. True dietary triggers are less common, but it is known that some people will crave particular foods early on in an attack. Some people find attacks will strike at a weekend or the start of a holiday. So stability is often key for a brain that is potentially susceptible to migraine. Headache diaries can be a really useful way to explore triggers and patterns.

The effect of hormones

Hormonal, menstrually related migraine usually begins at puberty. These attacks are often more severe than migraine at other times. Typically migraine will be experienced during the period, as oestrogen levels fall. The prostaglandins released with a period are also linked with migraine, so those with heavier more painful periods can be particularly prone to hormonal migraine.

If we take the combined pill, migraine is common in the first few days of the week off, (the pill-free interval) when oestrogen levels fall. The way pills are taken can be customised to promote hormonal stability and reduce migraines. Combined pills aren’t suitable to take if we have migraine with aura.

In pregnancy, many women experience fewer migraines, as oestrogen levels are steady, but the postnatal period with hormone levels dramatically falling, is a common time for migraine to flare.

At perimenopause with changing and fluctuating oestrogen and progesterone levels, we commonly notice hormonal migraines will worsen. Episodes are more common, last longer, are more severe, and are less predictable when they will strike as cycles become irregular too. Perimenopause is also a time when inflammation levels rise, and periods often become longer and heavier, which also influences migraine.

Postmenopausally migraine often really improves, although it doesn’t necessarily resolve completely. 

What about HRT?

As migraines are often linked to falling oestrogen levels, stabilising levels with hormones, contraceptives or HRT, can sometimes be beneficial. Some types of migraine though can be triggered by higher levels of oestrogen.

The response to HRT is variable, it can really help some people but on occasion can worsen migraine, especially when first started. Stability is key, so ideally oestrogen patches with a continuous progestogen is preferred. It’s important to start with a low dose and build up very gradually. Transdermal oestrogens like patches, gels or sprays are preferred over tablets.

Migraine specific treatment

It’s also important to look at what medication you use at the start of an attack – the triptan medications can be really effective, and one of these, Sumatriptan, is now available over the counter. There are different types, some work more quickly than others and some last longer, so it can be helpful to try more than one to see which suits you best. It is important not to take them on more than 10 days each month, as frequent use can actually trigger headaches. If you are needing them more than this it’s worth looking at preventative medications. 

There are a number of preventative options, some of which can also help with hot flushes and night sweats. Preventatives are usually continued for around six months and then slowly reduced. If migraines flare when the dose is weaned, then it can be increased again. We aim for the lowest dose needed to control the migraines.  

Lifestyle

Stability is key, so when looking at triggers and thinking about the impact of lifestyle, sometimes we will notice that late night or glass of wine at the weekend, extra coffee or missed meal in the week or an unusually intense exercise session may have precipitated an attack. We may find these factors particularly affect us if we are also at a lower oestrogen time of the cycle, for example around the time of a period.

Stress levels certainly play a significant part too, so looking at work-life balance, prioritising downtime and support like CBT can be really helpful in the management of migraine too.

Magnesium citrate or glycinate at a dose of 400-600mg daily can be helpful for migraine, and also support sleep, so is a great option to consider. It can have a laxative effect, so can be good to build up the dose gradually.

Useful resources

Managing your migraine by Dr Katy Munro

Headache diary Migraine Trust