Hormonal Headaches and Migraines

Hormonal Headaches & Migraines: A Women's Health Issue

Headaches and migraines. Most of us have experienced one or the other as some point – and know just how miserable they can be. It’s likely, too, that you’ve noticed a connection between headache or migraine symptoms and hormone shifts – and  you’d be exactly right.

Hormonal shifts can be a huge trigger and explain why headaches are far more common in women, with migraines three times as common in women than men. It also explains why for many women they first show up when they first start getting their period or in their late teens/early 20s and drop by 50 percent or even disappear completely after menopause.

Unfortunately, many doctors don’t take women’s reports about their hormonal headaches and migraines seriously. In fact, there’s a long history of medical racial and gender bias that has led to doctors denying women’s headache and migraine experiences. In one study of over 1,200 individuals seeking care for headache from a primary care provider, researchers found that 94 percent of the 377 patients who turned in a headache diary met criteria for migraines, yet at least 25 percent did not receive a diagnosis of migraine. Black women, due to systemic racism and the institutionalized belief that black women don’t feel as much pain, can ‘just handle it’, or are ‘drug-seeking,’ are routinely and systematically under treated for pain – including migraines. If you’re interested in learning more about gender and racial bias in women’s pain, and in migraine specifically, listen to this fascinating conversation I had with Joanna Kempner, PhD. author of Not Tonight: Migraine and the Politics of Gender and Health. And if you feel your doctor isn’t taking your symptoms seriously, it’s time for an honest conversation – or perhaps even a breakup – so you can get the care you deserve.

Women are too often told by doctors that our hormone-related symptoms are not significant; that they’re just “normal,” or that they are over-reacting – in other words, that it’s all in their heads. But hormonal headaches and migraines are not just ‘all in your head.’ Migraines are actually described in the medical literature as one of the most common, disabling gynecologic conditions, and menstruation as one of the most potent migraine triggers.

Further, even if you are given a prescription for your headaches or migraines, they don’t always work, as you’ll learn soon; many may actually become a headache trigger, and they carry side-effects that can be anything from unpleasant to serious.

The bottom line is that your hormonal life should never have you in chronic or even regular discomfort. I’m not opposed in any way to helpful pharmaceuticals, but I do believe it’s important to be informed and empowered about a broader range of options than most doctors know, to reduce and prevent symptoms naturally whenever possible, to try to get to the root causes leading to your symptoms, and avoid medications that may be doing more harm than good in some cases. So, I’m going to break down what you need to know about hormonal headaches and migraines, including what causes them and how to prevent them from recurring .

Menstrual Cycle Headaches & Migraines

Two types of headaches most commonly occur during our menstrual cycles: tension headaches and migraines. Tension headaches typically feel as if there’s a pressure band wrapped around your head, or like a pulsing in your temples or behind your eyes, and women commonly experience them before their periods start – but they may not have a uniquely hormonal cause and can be due to other common headache causes that occur coincidentally around your period, particularly if your period is a stressful time for you in general.

Menstrual migraines have a well-established hormonal basis. If you’re a migraine sufferer in general, unfortunately, you’re more predisposed to having hormonally triggered ones, too. As many as 70 percent of women ‘migraineurs’ experience a menstrual association. Don’t you feel lucky! However, it is possible to only have menstrual migraines – called pure menstrual migraines – and not have them otherwise. Here are some the known or suspected links between our cycles and migraines.

As Estrogen Drops, Serotonin Does, Too

During the first half of the menstrual cycle your estrogen level rises in order to thicken the uterine lining, creating  a rich, nourishing bed for an embryo, should pregnancy occur. Just after ovulation, if pregnancy doesn’t occur, estrogen rapidly declines, reaching its lowest level just before your period starts. This drop in estrogen during your period may trigger a headache and is a proven migraine trigger. Along with this decline in estrogen, there is decline in the neurotransmitter serotonin, which relies on estrogen for its production. This drop in serotonin is thought to be a major contributor to hormonal migraines, leading to more sensitization of the meningeal nerves, as well as the release of something called substance P which causes blood vessels in the brain to dilate, causing migraine pain.

We Have a Lower Pain Threshold Before Our Periods

Estrogen also regulates pain through chemicals in the brain, called endorphins or enkephalins. When estrogen levels are high, the brain is more efficient at responding to pain by releasing these, which dull pain signals received by the brain. But when estrogen levels are low, the brain doesn’t intercept these pain signals as effectively – which is why everything hurts more before our periods – including headaches and migraines. Menstrual migraines tend to be more severe, last longer, and are less responsive to usual medication therapies.

Histamine Gets Into the Act

Another hormonal trigger of menstrual cycle-related migraines is the estrogen-histamine connection. Histamine is released from immune cells called mast cells in response to getting exposed to allergic triggers and certain toxins. This can cause a whole host of generalized symptoms, from headaches, anxiety, and insomnia, to abdominal pain and diarrhea, dizziness, hives, and eczema, to name just a few that you might be familiar with if you suffer from allergies. These symptoms are also commonly increased during our cycles – loose stools before our periods, migraines, a flare of eczema, for example.

What’s the connection? Histamine is not just involved in immunity, but neurologic and hormonal functions as well, and it is intimately involved in reproduction, becoming particularly active around ovulation and our periods. It is tied to estrogen production, which in turns stimulates mast cells to release more histamine. At the same time, estrogen reduces the production of a naturally occurring enzyme in our blood, DAO, which clears the histamine. Histamine in turn, stimulates the ovaries to produce more estrogen, so there’s a cycle of increasing estrogen and histamine that occurs post ovulation and premenstrually – and may, for some women, be a trigger and vicious cycle of headaches and migraines.

It Can Happen Around Ovulation, Too

For some women, even the decline in estrogen post-ovulation is enough to trigger a headache or migraine, and some women experience them both post-ovulation and premenstrually. Not fun at all! If your hormones are generally in healthy ranges, you may be less likely to experience headaches and migraines, but some women may also be producing less serotonin due to low carbohydrate diets, stress, or a genetic predisposition to menstrual migraines. Of course, anything that’s already connected to causing headaches: too much caffeine or sugar, not enough sleep, loud noises, and it bears repeating, stress, are all risk factors – so as tempting as it might be, we can’t just blame it on our moms and our genes!

Post-Pregnancy Headaches & Migraines

Where we are hormonally in our life cycles can play a major role in headaches and migraines, too. During pregnancy, for example, your estrogen level soars, and most women actually see an improvement in headaches and migraines, but right after a pregnancy ends, that high estrogen level plummets, and for some women, this leads to hormonally triggered headaches or migraines after giving birth, a miscarriage, or an abortion.

In fact, headaches and migraines during these tender times are relatively common; as many as one in four women will experience a migraine in the first two weeks after giving birth and fifty percent will get a migraine within the first month. For new moms, besides the dramatic drop in estrogen, missing out on sleep adds yet another possible trigger. If you’re already prone to headaches or migraines, using the tips in this article to prevent them can at least reduce one unwelcome post-pregnancy challenge.

Perimenopause & Migraines

Most women who experience migraines will have their onset before their 40s, and most women who have experienced migraines during their lives will actually stop having them once they’ve gone into menopause (defined as having no period for one year) which for most women is around age 52.

But during our 40s and into our early 50s, as our estrogen levels naturally begin to fluctuate and eventually decline, we may experience a wide range of new sensations – and symptoms including sleep loss, vaginal dryness, hot flashes, and night sweats. This can also lead to a new onset of migraines, or for women who already experience them, an exacerbation. These may persist for a few years even after your last period, showing up cyclically at the time when you’d have been premenstrual, as your hormones still ebb and flow, just not enough to cause menstruation. You may choose to use hormone therapy if your peri-menopausal symptoms are quite troubling, or medications for occasional headaches or migraines; the strategies below can also help you until those migraines naturally disappear on their own.

Migraines & Hormonal Medications

While some women experience relief from cyclic headaches if they take an estrogen-containing form of the Pill, some actually experience headaches from the Pill. This may be more common if you take an estrogen-containing oral contraceptive, with a placebo week. In this case, you’re on the hormone-containing pills for 3 weeks, followed by one week of inactive ‘placebo’ pills, leading to a drop off in estrogen that can trigger headaches or migraines. These are called estrogen-withdrawal headaches. To avoid this, you have to skip the placebos and stay on a steady dose all month – though then you won’t get your period.

Similarly, if you miss one of the active pills or you decide to discontinue hormonal birth control completely – you’ve got it: your estrogen level will drop and it's headache or migraine city until your hormones start to level off naturally. As the Pill can increase some women’s risk of stroke, if you experience migraines for the first time after starting the Pill, it’s critical to stop the Pill and contact your health care provider – and make sure your concerns are taken seriously. Migraines with aura are contraindication to using hormonal birth control due to the risk of stroke.

Coming off of Estrogen Replacement Therapy (ERT), which is used to keep menopausal symptoms like hot flashes and vaginal dryness at bay, can trigger headaches or migraines, especially if you stop suddenly. Weaning yourself off of ERT gradually over about six weeks can help circumvent this.

6 Steps for Preventing Hormonal Headaches & Migraines, Naturally

It Takes Whole Woman Approach

Most experts agree that migraines are not simply a hormonal problem – they  are the result of the brain's reaction to a complex interaction among hormones, genetics and environmental factors. And since not all women experience them, one's internal environment – levels of inflammation, genetics, gut health, and other factors – influence estrogen levels and also how the brain responds. That's why in my practice, I always take a whole woman approach to healing.

Hormonal headaches and migraines can make you feel miserable and even make you miss days of enjoying your glorious life. They also have a lot of complex causes – including our hormones. Fortunately, there’s a lot you can do to prevent them, reducing their frequency, and treat them reducing their severity, your need for medication – or possibly become free of them altogether. I recommend giving your plan at least 3 months, using the 6 steps below simultaneously. You do not have to use all of the supplements I list but  do make the dietary changes and lifestyle changes (i..e, stress reduction)  and pick 2 to 3 supplements and 1 or 2 herbs to support your journey to overcome migraines.

Step 1. Identify Your Triggers with a Headache Journal

As you’re getting started on treating your headaches and migraines, even if you’re going to go a medication route, a headache journal is a fabulous first step in identifying headache and migraine triggers so you can sort out what’s hormonal, and what’s something else you might be exposed to that sets off your symptoms. Pay attention to when the headaches/migraines occur, what you were doing in the 24 hours prior, notice foods, environmental triggers, stress, and look for other triggers (described below for headaches and migraines).

When you start writing down when you’re experiencing your headaches and migraines, you’re very likely to notice patterns. You might discover that your hormones are the biggest factor, but you may also notice that you’re having a couple of extra glasses of red wine just before your period or now that you’re in perimenopause – and that’s what’s really setting your headaches or migraines off.

With headaches, we can often pinpoint the cause: too much caffeine, not drinking enough water, having one glass of wine too many the night before, a stiff neck, stress, or not getting enough sleep. The throbbing feeling in your temples or behind your eyes, or the feeling of wearing a vice grip for a hat can make it hard to function.

Known migraine triggers, which may be other than or concurrent with hormonal changes, include:

• caffeine
• red wine
• alcohol
• aged cheese
• sugar
• nitrites found in hot dogs and deli meats
• food additives like msg
• low blood sugar
• stress
• neck and shoulder tension
• certain medications (including some headache medications!)
• perfume and other strong odors,
• bright lights
• travel

As you identify headache or migraine triggers, remove them and track during your next cycle, or for a month to six weeks if you’re not cycling, to see if the change made a difference or not in migraines or headaches.

Headache Medications – A Surprising Headache Trigger

A really surprising trigger can be your headache or migraine medications. Yes, you heard that right. While medications can certainly nip a nasty headache in the bud, most people don’t know this but there is a phenomenon called medication overuse headache (MOH). When you take pain medications for headaches, including Tylenol, aspirin, caffeine, ibuprofen, or opioids, on a regular basis, and even triptans for more than ten days per month these medications actually start to cause headaches, and make your headache and migraine frequency and severity worse, creating a vicious cycle where you take more and more of the meds that are making you worse!

As crazy and scary as this might seem to you to try, stop all of your pain medications for a few months. You might be surprised to find that you are actually having fewer headaches!

Step 2: Balance Estrogen

While our estrogen levels naturally fluctuate throughout our monthly and life cycles, many women experience estrogen extremes – either too low or too high. While I’ll be sharing additional articles soon on balancing estrogen, here are the big things to look out for and do.

Low estrogen is most commonly caused by being undernourished or underweight. This is very common for high intensity athletes, including dancers, avid yoga practitioners, and women on restrictive (which can sometimes be misinterpreted as extremely healthy) diets. At the extreme, you might not be ovulating or having cycles at all, but if you are, and are experiencing headaches or migraines, reducing your exercise intensity or increasing your food intake, is really important.

If you experience high estrogen levels, sometimes called estrogen dominance, you may also experience heavy periods, cyclic breast tenderness, mood swings, bloating or other estrogen related symptoms. High estrogen levels can be due to hormones that you might be inadvertently  getting through your diet- for example, in meat and dairy, from hormones given to the animals, or naturally occurring in animal milk. Plastic food packaging , plastic water bottles, chemicals that are found in cosmetics and other common products all also act as endocrine disruptors – mimicking and falsely elevating estrogen. Removing these triggers from your pantry, home, and bathroom can reduce these exposures and blood levels of what are called ‘exogenous' or foreign estrogens.

Step 3: De-Stress

I know it’s so easy to say, but stress, anxiety, and depression make us more susceptible to headaches and migraines premenstrually and at other times in our lives. The fact that women experience more stress – including hidden stress – than men – doesn’t help. Sexual harassment and domestic abuse, , for example, can cause headaches, among other symptoms. Reducing or getting help with any stressors you can, and reducing modifiable stress is an important step in reducing your headaches.

Additionally, coping and relaxing strategies, from meditation and yoga to taking needed down time (and sleep time – fatigue is a major headache and migraine trigger!) to Cognitive Behavioral and other forms of therapy can all help. They can also help to balance your hormones, which can be disrupted by stress.

Neck tension has become especially common due to chronic sitting and use of electronic devices. We’ve become so used to holding tension in our neck and shoulders that we think it’s normal! When you’re sitting at the computer, be mindful of your posture to minimize the stress you’re putting on your neck and shoulders. Stretching or moving through gentle yoga poses either each morning, evening, or during a mid-day break can help alleviate tension in these areas.

Regular massage may also help and if you have a history of headaches or migraines, your insurance may actually cover them. (Just make sure you’re booking a “medical massage” and check with your insurance carrier first.) If your insurance doesn’t cover massage therapy, it will likely cover physical therapy sessions which can be super helpful; your primary care provider can give you a prescription for a weekly (or more if needed) session.

Lavender and peppermint essential oil aromatherapy. At least one study shows that even simply breathing in lavender scent for about 15 minutes can help ease a migraine. An approach I use in my practice is to have my patient apply two to three drops of either lavender essential oil to their temples, or a few drops onto either wrist. While you can safely use an undiluted essential oil in this low amount, I prefer to dilute a few drops of essential oil in a teaspoon of a carrier oil such as almond oil, then applying this mix. A warm bath with five to seven drops of lavender essential oil can also work wonders. Peppermint oil, applied to the temples, also slightly diluted, can be effective as well. One study found that a drop applied to the temples can relieve migraine pain in as short as 30 minutes. These are safe for use in pregnancy and while breastfeeding.

Step 4: Use Food as Medicine

There are several ways that making some tweaks to your eating habits could help.

First, switch to an anti-inflammatory diet. A Mediterranean-style diet that emphasizes legumes, 8 servings of fruits and veggies daily, fiber, and plenty of leafy greens, while also supporting healthy daily bowel elimination and gut flora, is amongst the important steps you can take to optimize your estrogen levels throughout your cycle. Along with this, you'll be reducing the pro-inflammatory foods in your diet, particularly sugar, red meat and poultry, and processed foods, while adding antioxidant rich fruits and vegetables and good quality oils can reduce your headache frequency.

If you struggle with inflammation or blood sugar problems read my book, The Adrenal Thyroid Revolution to help you learn to cool down the heat and keep your sugar steady as well as learn to dial back stress and dial up good quality sleep!

Fiber plays a direct role because it not only helps get things moving, but it helps to regulate estrogen levels. Also, many of my patients who suffer from regular headaches and migraines also suffer from constipation, and relieving the latter has, itself, hit the brakes on migraines and headaches. A good goal is to aim to get about 35 grams of fiber a day. If you’re not there yet (the average American only gets about 15 grams a day), work your way up slowly by adding more fruits, vegetables, nuts, beans, and whole grains to your diet. Two tablespoons of flax seeds daily can help balance estrogen and also relieve constipation. And leafy greens like kale and broccoli also provide important fiber – and help regulate your hormones.

You can also use food to keep your serotonin levels steadier, which can in turn help prevent hormonal headaches and migraines. For all women, carbohydrate restriction can also play a role – as it could mean you’re not producing the serotonin I mentioned which is so important for headache and migraine prevention – so make sure to increase your carb intake. The key to this is increasing your intake of complex carbohydrates like oats, brown rice, beans, especially before your period if you experience premenstrual headaches or migraines. That’s going to do the blood vessels in your brain a big favor.

Finally, when it comes to food and menstrual headaches and migraines, it is possible that you are experiencing the histamine-hormonal headache connection. You can learn much more about this in my blog/podcast Histamine Intolerance: Could It Be Causing Your Symptoms. 

Step 5: Migraine-Relieving Nutritional Supplements

Besides food, there are also dietary supplements that have been found to relieve headaches and migraines. These are my go-to supplements, all of which are safe during pregnancy and breastfeeding.

Riboflavin (vitamin B2):  Riboflavin has been shown to safely prevent recurrent migraines by 50 percent compared to 15 percent for placebo – that’s a lot! Its benefits are likely a result of increased efficiency of the mitochondria. (Decreased mitochondrial function is an under-recognized contributor to migraines.) It may take about a month to notice results but hang in there. It’s often very effective. If you are on a beta-blocker for migraine prevention, riboflavin has been shown to enhance the benefits so it may allow you to lower your dose or get better results from the dose you are taking. This can be taken during pregnancy and in fact is considered a migraine prevention of choice during this time. Dose: 400 mg/day.

Magnesium: This supplement can help prevent migraines generally and may be especially helpful in preventing migraines associated with your period – hallelujah sister! It’s also been shown to reduce migraine severity. According to the American Migraine Foundation, daily doses of 400 to 500 mg of magnesium may help prevent migraines in some people. They say it’s especially effective for migraines related to menstruation, and those with accompanying aura, or visual changes. It may take as long as three months to see results, so hang in there with this one, too. Another study found that 600 mg daily may prevent migraines; this is the dose I most commonly recommend.

Calcium: in addition to the benefits of calcium on our bone density, 500 mg daily of calcium can prevent and reduce PMS symptoms including headaches, cramping, moodiness, and food cravings by half.

B-Vitamin Combo: A combo-cocktail of vitamin B6 (25 mg), vitamin B12 (400 mcg) and folic acid (2 mg) has been shown to reduce migraine-related impairment in 50 percent of migraine sufferers after six months of daily use. This is thought to be due to a reduction in the blood-vessel irritating amino acid homocysteine, which may contribute to migraines. Of note, high homocysteine can be the result of low folate or folic acid intake, and may be more common in those with a variation in their MTHFR gene, which affects from 10 to 30% of people. To bypass this problem. even if you don't know your genetic type, use methylfolate instead of folic acid. If you're pregnant, don't exceed 1 mg of methylfolate daily.

Step 6: Herbal Therapies for Migraines and Headaches

Several herbal medicines have been found to play a powerful role in hormone regulation, as well as headache and migraine pain reduction. Here are my top choices:

Ginger: Traditionally used to treat pain and inflammation, this herb can nip migraine pain in the bud. A study of 100 migraine sufferers, both sumatriptan (50 mg), a common drug used to stop migraines at their onset, and ginger powder (250 mg) equally decreased the severity of attacks within two hours, with equal satisfaction with pain relief in both groups and far more side-effects in the sumatriptan group. It also helps reduce migraine-associated symptoms like nausea. Dose: up to 2 g/day. Safe for use during pregnancy and breastfeeding.

Curcumin: Several small studies suggest curcumin, an active ingredient in the herb turmeric, may reduce migraine frequency, pain severity, and duration. A 2018 study found that people who took a combination of omega-3 fatty acids and curcumin had fewer and less severe migraine attacks over 2 months than they usually did, while a 2019 study found that individuals taking a combination of curcumin and Co-enzyme Q10 reported a reduction in headache days, severity, and duration. Curcumin is valued for its anti-inflammatory effects and may also have some anxiety-relieving effects; it's also quite safe and is one of the herbs I rely on for pain relief in my practice. A typical dose is 500 mg twice daily, but this may vary depending on the preparation, so follow the dose on the package. Avoid during pregnancy; safe for use during  breastfeeding.

Vitex: Not just valuable as a PMS remedy, vitex can lead to overall steadier estrogen levels and prevent menstrual migraines. Dose: 180 to 220 mg daily in capsule, once or twice daily, or 5 mL (about 1 measured tsp.) daily of liquid extract. Generally avoid during pregnancy; safe for use during  breastfeeding.

Feverfew: Feverfew is a natural anti-inflammatory. It both prevents migraines and reduces migraine severity with five substantial studies supporting its use. If you are on blood thinners, this one is not for you – it can interfere with your medication and increase bleeding. Dose: 25 mg daily. Avoid during pregnancy; safe for use during  breastfeeding.

Butterbur (also called Petasites): Used for over 1,000 years, this herb is a respected anti-inflammatory which can be used preventatively for significant reduction in migraine frequency. It may take several months before you notice major improvement but give it a try. A 2012 study on evidence-based therapies for migraine included this herb as effective migraine prevention strategy when taken as 50 to 75 milligram doses twice daily. Purchase only products that say “PA-free” on the label. Avoid during pregnancy and breastfeeding.

Next Step: A Migraine-Free Life!

What’s clear is that our hormonal headaches need to be taken more seriously. There’s a reason we get more headaches and migraines than men – but suffering with them just because of our hormones is not an acceptable answer, nor is trying one medication after another if they’re not working. I hope that you now see that  your headaches and migraines are not just in your head – even if stress is contributing that’s affecting you physically, too  – and that there are natural approaches that might help you turn things around so you can start to be your own healer, and hopefully before too long, become headache and migraine-free.