SYMPTOM: Migraine

Migraines and Hormonal Headaches: Understanding and Managing

Migraines and headaches often have a hormonal component, particularly for women. Understanding their relationship to your menstrual cycle and identifying triggers can significantly improve management. During perimenopause, many women experience worsening migraines due to fluctuating estrogen levels and declining progesterone. While most commonly associated with dropping estrogen levels, migraines can also occur when estrogen rises or simply due to hormonal changes. For some, decreasing progesterone may be the culprit.

Here's a bit of a deeper dive for you

Fluctuations in estrogen levels, particularly the sharp drop before menstruation, can trigger migraines in many women. This is because estrogen influences neurotransmitters and pain pathways in the brain, including serotonin and calcitonin gene-related peptide (CGRP), which are involved in migraine pathophysiology. Jerilyn Prior, a prominent researcher in women's hormonal health, emphasizes that progesterone can also play a protective role, especially during perimenopause. She suggests that maintaining adequate progesterone levels may help mitigate migraine frequency and severity during this transitional period. Additionally, metabolic factors can influence migraine occurrence. Fasting has been identified as a common trigger, with studies showing that up to 50% of migraine sufferers report fasting as a precipitating factor. Insulin resistance, which affects about 16% of migraine patients, can also exacerbate migraines. This metabolic condition can lead to fluctuations in blood sugar levels, triggering or worsening migraine attacks. Managing blood sugar levels through diet and lifestyle modifications may therefore be an important aspect of migraine management for some individuals.

Some Management Strategies:

Acute Management:

At the onset of symptoms (e.g., 'fuzzy' head, thirst, flushing) as well as the traditional aura ie visual disturbance:

1. High-dose paracetamol and quick-release non-steroidal anti-inflammatory (as a one-off) (ensure discussed with your prescriber ensure this is safe and appropriate for you)

2. Domperidone for nausea relief and improved medication absorption

3. Additional considerations:

   - Caffeine (coffee/tea) and carbohydrates/sugar

   - Hydration with water or electrolytes

   - Prescribed triptans

   - Omeprazole for gastric protection if needed

Preventative Management:

1. Supplements:

   - Calcium (1000mg daily) (caution if you have cardiac disease or are older >50yo

   - Magnesium (400-600mg nightly, preferably di-glycinate or l-threonate)

Hormonal Management:

Dr Sam says "this is really under used and under recognised with respect to migraines related to hormones"

• Estrogen patch applied during the luteal phase (or continuously if Mirena IUD is in place), combined with Utrogestan in the luteal phase
• Utrogestan 100-300mg nightly during the luteal phase (as per Professor Prior)
• Estrogen delivered via a patch provides more stable levels, which is better for migraineurs
• In persistent migraines use of GnRH analogues (hormone blockers) with add back hormones can stop the flux of hormones and hence migraines aren't triggered

3. GP-prescribed medications:

   - Beta-blockers (e.g., propranolol)

   - Anti-epileptics (e.g., topiramate)

   - Anti-depressants (e.g. nortriptiline)

4. Lifestyle Modifications:

   - Avoid known triggers (e.g., wine, chocolate, stress, sleep disturbance)

   - Maintain regular eating habits

   - Incorporate regular exercise

Remember, individual experiences may vary. Consult with your healthcare provider to develop a personalized management plan.