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Charisse Litchman MD, FAHS is a neurologist, headache specialist, and medical advisor to Nurx — the convenient and affordable way to get medication (including birth control and migraine treatment) prescribed online and delivered to your door. In this article, she explains how puberty, periods, pregnancy, perimenopause, and the pill may affect your head.
Hormones and headaches
Both men and women can suffer from chronic headaches, but women are more likely to experience migraine. That’s because fluctuating sex hormones, especially estrogen, play a large role in triggering migraines and affecting the severity of migraine pain. According to the Migraine Research Foundation, boys develop headaches more often than girls prior to puberty. Migraines become more frequent in girls after puberty because of the changing estrogen levels they experience.
At least half of women who suffer from migraines will experience worsened headaches with their periods, called menstrual migraines. During the menstrual cycle, there are biological changes — including changes in the levels of your sex hormones (estrogen and progesterone) — which cause many changes in your body, both physical and emotional. The increase of headaches during your periods is directly related to the changes in sex hormone levels, especially the drop of estrogen levels and the increase of prostaglandins (a naturally occurring fatty acid) just before your period.
How the pill affects migraines
Taking oral contraceptives can either improve or worsen the frequency and severity of migraines. The greatest benefit is from steady doses of estrogen throughout the month. Estrogen levels dip while taking the placebo pills, so women who experience headaches during the placebo week often benefit from skipping the placebo pills to prevent a period.
The use of oral contraceptives is generally safe for most women who suffer from migraines. However, women who experience aura with their migraines may have a greater risk of stroke, heart disease, or blood clots from taking hormonal contraception containing estrogen.
Oral contraception containing estrogen also poses a greater risk of blood clots in women who have a history of previous blood clots or a family history of blood clots and possibly in some women who have had previous miscarriages. The increased risk of stroke and blood clots was found in studies in which the amount of estrogen in the oral contraceptives was higher than in many of the pills we use today. Therefore, the risk of stroke and blood clots may be less when using pills containing lower doses of estrogen. More studies are needed, but currently, estrogen-containing pills are not recommended for women who suffer from migraine with aura. Smoking while using estrogen-containing pills further increases the risk of stroke and vascular heart disease in women who suffer from migraine with aura.
The use of hormonal contraception containing only progestin, including progestin-only pills, the birth control shot, a birth control implant, and the hormonal IUD, do not seem to increase the risk of stroke or heart disease in women suffering from migraine with aura.
Women who develop their first migraines after starting oral contraceptives should stop the pill and contact their primary care provider right away.
Migraine in Pregnancy
The majority of women who suffer from migraines prior to their pregnancy will see an improvement in the severity and the frequency of their migraines, especially in their second and third trimesters — approximately half in the first trimester and over 80 percent in the second and third trimesters. While only a minority will have their headaches stop entirely during the first trimester of their pregnancy, around 75 percent will have no headaches in their third trimester.
Women who experience migraine with aura are less likely to see their headaches improve during pregnancy as much as those who suffer from migraine without aura. Women who had suffered menstrual migraines (migraines that come along with their periods) tend to have more painful but not more frequent headaches early in pregnancy, but they too will enjoy less frequent headaches later in pregnancy.
Headaches and Menopause
Over 90 percent of people with migraines start having attacks before age 40 (most start in their teens and 20s). Most women who suffer from migraine headaches will stop having migraines after menopause, especially those women whose migraines were worse with their periods. A woman is considered to reach menopause when her periods have stopped for one year.
However, the time leading up to menopause (perimenopause) is associated with new hormonal fluctuations, when levels of estrogen and progesterone rise and fall. Similar to how the hormone levels changing with periods can lead to headaches, the hormonal fluctuations of perimenopause can lead to migraines starting for the first time or worsening. This worsening, which is experienced by almost half of female migraine sufferers, can last until the estrogen levels have dropped enough in menopause.
Some women will notice that for several years their migraines will remain monthly even though they do not get a period. This is because the normal hormonal cycle has continued enough to trigger a migraine but not enough to cause a period. Women may also experience more headaches during menopause because of sleep difficulties, stress, and mood changes that accompany menopause.
The Bottom Line
Headaches often have complex roots and often aren’t caused by a single factor, but for many women, hormonal fluctuations play a big role. Hormonal contraception may help, and additionally, prescription headache medication that you take for pain relief or daily for prevention can help get women’s migraines under control.
About the Author
Charisse Litchman MD, FAHS is a neurologist, headache specialist, and medical advisor to Nurx. She received her undergraduate degree at Wesleyan University and her medical degree at Yale School of Medicine. After completing her internship at Yale New Haven Hospital, she completed her neurology residency at Cornell-New York Hospital. She began a solo private practice in general neurology and became board certified in headache medicine in 2008. A former Assistant Professor of Clinical Neurology at Yale School of Medicine, Charisse has published articles in headaches and multiple sclerosis and edited the first textbook on a rare soft tissue tumor. She has earned a certificate in Medical Editing and Writing from the University of Chicago. Charisse has three children and lives in Connecticut with her husband Mark and her two dogs.