Women’s health articles

Menstrual migraines and other hormonal headaches

by Marcy Holmes, NP, Certified Menopause Clinician

So many of our patients come in to the practice after being told by their conventional doctors that their hormonal symptoms are all in their head. In the case of menstrual migraines and hormonal headaches, they may be right!

Many women react to hormonal fluctuations with head pain, often in a cyclical fashion that corresponds to their monthly ebb and flow of estrogen and progesterone. Conventional doctors and headache specialists often overlook this common headache trigger, and even when they don’t, they offer little in the way of long-term solutions. Most primary care physicians will write a prescription for a pain reliever or birth control pills or refer these patients over to their ob-gyn.

After seeing many of these women over the years, we are happy to report that a majority of our patients find their headaches become less frequent or disappear altogether once they systematically address their hormonal imbalance through diet, optimal nutrition, and short-term bioidentical hormonal supplementation.

Recently, we looked at natural relief for chronic headaches and migraines of all sources. Now we’d like to delve a little deeper into relief for hormonally-based headaches. Even if headaches have never been a concern before, many women may become more sensitive to their hormones as they age and may begin to experience hormonal headaches or menstrual migraines for the first time as they enter perimenopause.

We’ve had great success in treating the root cause of these hormonal headaches and migraines with the holistic approach that forms the basis of our Personal Program. It can take a bit longer than popping a pill, but I assure you, relief from your headache is only one of the long-term benefits.

Who gets hormonal headaches?

Women who are susceptible to hormonal fluctuations often suffer with menstrual headaches or migraines just prior to the onset of menses, when there is a natural drop in progesterone levels (see our diagram of the menstrual cycle.) But headaches may also occur at ovulation, when estrogen and other hormones spike, or during menses itself, when estrogen and progesterone have bottomed out.

Hormonal headaches can come on suddenly or become more unpredictable in perimenopause or at menopause, when a woman’s hormones are really shifting. Some women who have never experienced headache or migraine before begin to suffer with regularity. I once knew a woman with incapacitating migraines in her initial year of menopause, similar to what she recalled experiencing at puberty/menarche, but without headache pain for the 40 years in between! Every woman is different, and tuning into your body’s own unique signals is the first step in any kind of natural prevention or treatment.

As with any other kind of headache or migraine, tracking the onset of your pain with our Wellness Diary or another journal will help you get a handle on the pattern and cause. If you are still menstruating, I recommend charting the days of your period for a few months with the same journal. This will give you a better understanding of the basic ebb and flow of hormones in your system each month and how they may relate to your headache or migraine. For an explanation of how hormones orchestrate your period, see our section on the menstrual cycle.

You should be aware that most headaches are multifactorial and may have overlapping triggers. Hormones are often part of the headache/migraine cascade, even if they haven’t been officially identified. Any woman with regular headaches or migraines can benefit from improving her overall ratio of estrogen and progesterone.

The estrogen–progesterone connection

Most hormonal headaches occur when levels of estrogen are off-kilter in relation to natural levels of progesterone. As noted above, for many women this may be correlated with the naturally lower levels of progesterone that are normal before the onset of menses, when progesterone levels naturally drop off. Or less frequently, it may be a state of true progesterone deficiency as some women, especially during perimenopause and menopause, may experience unnaturally low progesterone levels that require supplementation. Only a blood test or saliva test can give you a snapshot of what your levels actually look like.

I recommend testing progesterone levels during the mid luteal stage of your menstrual cycle. Depending on how many days are in your cycle, this usually occurs after ovulation, somewhere around day 21 of a classic 28–day cycle. Some practitioners will provide a simple saliva test; others think it is a bit controversial and recommend the more expensive blood test. At Women to Women, we start with one but offer both, depending on the woman’s age and severity of symptoms.

Typically, what we find in women of all ages is that “baseline” progesterone levels are acceptable but the ratio of progesterone to estrogen is off. This doesn’t mean your estrogen levels are abnormal (although, if you’re worried, you can test your estrogen levels as well with a blood panel). Most of the time it simply means the level of estrogen is out of sync with the opposing progesterone level.

If your headaches occur around ovulation, this can represent a temporary state of monthly fluctuation that manifests as symptoms of PMS or breast tenderness and headache at ovulation, or it can become a more entrenched state and drag on through the entire luteal phase. One thing is certain, however: if the ratio of estrogen to progesterone is less than optimal for what your body needs to cope (and this is individual), you will have uncomfortable physical symptoms and, in susceptible women, hormonal migraines or headaches.

How does the ratio of estrogen to progesterone go awry? It may be that you are an “estrogenic” kind of person, one whose body readily converts progesterone into estrogen. It may also be that you are susceptible — as many of us are — to the rising level of xenoestrogens and other endocrine disruptors in our environment. These substances mimic estrogen in the body and can topple your delicate hormonal balance. (Keep in mind you may also have other dietary or stress–related triggers in addition to your hormones). Once you suspect that your headaches or migraines have a hormonal component, you can begin to do something about them.

Preventing hormonal headaches naturally

Getting to the root of these hormonal headaches means dealing with a temporary or chronic imbalance of estrogen in relation to progesterone. As we so often say, a healthy diet that avoids or eliminates simple carbohydrates, refined sugars, and processed foods is always the first step. Our lifestyle and nutritional guidelines can get you started.

The second step is to decrease or eliminate toxins that can be exacerbating your hormonal imbalance. For this, our two–week Quick-Cleanse can be very helpful. Again, it is always a good idea to be wary of endocrine–disrupting chemicals in your environment and avoid them to the degree possible — even the perfume in your cosmetics can be a migraine trigger.

The third step is to fill in any dietary gaps with nutritional supplements. Good choices to begin with are core nutrients like those offered in our Personal Program — a rich multivitamin, essential fatty acids, and calcium/magnesium. All are crucial to supporting your hormone balance and restoring a good progesterone-to-estrogen ratio. Additional nutritional support measures can also be considered, such as moderate soy, fresh ground flax seed, or other foods high in fatty acids, fiber, isoflavones, and lignan precursors.

As for specific supplements that can nip migraines in the bud, there are several to choose from. Principally, certain herbs have been used to prevent and treat headaches by herbalists for thousands of years, at least two of which are now solidly confirmed by scientists as effective in clinical trials: butterbur (Petasites hybridus) and feverfew (Tanacetum parthenium). The mineral magnesium and vitamin B2 (riboflavin) have both likewise been demonstrated to decrease migraine frequency in people who normally have multiple migraines a month. By effective, we mean at least a 50% reduction in migraine frequency.

Today there are various safe, over-the-counter migraine prevention formulas that combine these natural ingredients, and I’d encourage you to look into them because they can be especially helpful in combination formulas. For example, Migravent contains all four of the above ingredients: feverfew, butterbur, magnesium, and riboflavin. We are watching those patients who are taking this and will report back on their experiences. Further information on these products can easily be found on the web.

There are additional plant extracts and foods that women have long used in various cultures to ameliorate headaches and other symptoms associated with fluctuating hormones, including soy, black cohosh (Cimicifuga racemosa) and dong quai (Angelica sinensis). While we generally recommend that anyone considering the use of naturopathic remedies consult the advice of a qualified practitioner, you can also talk to your regular healthcare practitioner or call one of our Member Advisors to find out what may work best for you. For many women, a change in diet, nutrition level, and lifestyle is all they need to feel better.

Once you’ve established a basic core of nutrition, you may find that adding natural hormone supplementation at the right time of the month, specifically bioidentical progesterone, provides a great deal of relief. Most of our patients find that proper use of a low-dose bioidentical progesterone cream — in combination with the proceeding measures — gets rid of their hormonal headaches entirely. But for natural progesterone to be effective in this area, you need to know when to use it. Here are some guidelines based on the timing of your hormonal headaches.

	Using bioidentical hormones to abort hormonal headaches
•	For premenstrual and perimenopausal headaches and migraines
	The most likely triggers for headaches that occur premenstrually, or those in perimenopause, include a sensitivity to the natural drop-off in progesterone levels as the luteal phase of your cycle (second half) progresses, or alternatively, an ongoing progesterone deficit. For this pattern we recommend you apply the cream as directed during the last two weeks of your cycle.
•	Headaches and migraines at ovulation
	If you have mid-cycle/ovulatory headaches, they may stem from the elevation in estrogen which, in concert with spikes in FSH and LH, corresponds with ovulation. It is completely natural for estrogen to have the slight upper hand at this stage of your cycle. For a pattern such as this, evaluate your cycle history and based on your average cycle length, apply cream on or around day 12, or two days prior to ovulation. If you are not sure when you ovulate, you may want to try an over-the-counter ovulation predictor kit or use another natural method such as monitoring your mucus and basal body temperature (BBT).
•	Headaches and migraines during your period
	If menstrual headaches persist throughout your menses even after you’ve tried the natural balancing measures we’ve discussed, it may be helpful to try prescription–strength bioidentical estrogen supplementation, such as the estradiol patch, during your period. Talk to your healthcare practitioner about this.

Preventing birth control pill–related headaches

Many women on birth control pills report hormonal headaches on the second or third day of their placebo pills. We suspect these are similar to menstrual headaches, and are due to the relatively precipitous drop in synthetic hormones that women on BCP’s experience during their placebo week (the point in the cycle when you typically experience a withdrawal bleed).

Every woman taking synthetic birth control will feel better with optimal nutritional support, which will help their bodies metabolize and clear the synthetic hormones. Women on BCP’s can also use low-dose, bioidentical progesterone cream for support. We typically suggest using it on the days that correspond with days 7–21 of the pill package, or it can be tried during the last week, during the placebo pill phase. Alternatively, some women may want to try using a bioidentical estradiol patch during their week of placebo pills to see if that helps as well, but again, you will need to work with your healthcare to finesse these options.

If your migraines are really severe, you might consider extending the number of days you are on the active pills by actually skipping the placebo pills for a few months at a time. I don’t generally condone this, but it is a viable option for women who have difficulty in making certain lifestyle or dietary changes, or for those who don’t want to use bioidentical progesterone. This can be more easily be accomplished with “monophasic” birth control pills (all the pills in the pack contain the same dose) than with the “phasic” products (those with a gradation in dosages throughout the cycle). You simply skip the placebo and take, for example, 6–9 weeks of “active” birth control pills instead. (Unexpected breakthrough bleeding may occur and can be problematic, but you should at least be protected from pregnancy if you take your pills on time each day.)

Additionally, there is the option for women who elect to use BCP’s to shorten the “pill-free” interval, that is, to take the placebo pills for fewer days than the packet would indicate. If any of these options seem reasonable for you, talk to your healthcare practitioner about ways in which you might be able to modify your prescription. See our article about birth control pill use in perimenopause to learn more.

A word about hormone use and hormonal headaches

At Women to Women, we always begin treatment by encouraging our patients to describe to us how they treat themselves. We want to hear them voice their medical and personal history, dietary, lifestyle and emotional concerns. And while we believe that natural (bioidentical) hormone supplementation is an important therapeutic for some women, and can be particularly useful in treating hormonal headaches, we are always aware that hormones — even if they are natural — are very powerful. That’s why we recommend a blood test for any woman who is interested in using hormones, especially if she is nearing menopause. And it’s also why we think of any kind of hormonal supplementation as a bridge to natural, self-sustaining hormonal balance, not an end solution.

If you are still menstruating or within a year of menopause, you may want to discuss a trial of low-dose bioidentical progesterone, as described above, with your healthcare provider. In combination with other lifestyle changes it may help your body to become more progesterone–balanced without further supplementation. For headache or migraine relief we do not promote the use of synthetic progestins like Provera or synthetic HRT combinations because they act more as vasoconstrictors and can actually worsen headache symptoms! The pharmacokinetics of real, bioidentical progesterone is entirely different as it is metabolized instinctively by the body.

Nonetheless, even on a low-dose, bioidentical hormone you should continue to exercise caution and tune in to your body’s signals. If you are using bioidentical progesterone and experience increased headache or other PMS symptoms such as breast tenderness, or you begin to sense these symptoms at ovulation, you may be hard-wired to convert extra progesterone into estrogen, in which case additional progesterone may not be a good choice for you. With any persistent heavy bleeding, unusual spotting, breast tenderness, or other serious symptoms while using bioidentical progesterone products, discontinue use and contact your healthcare provider — further evaluation may be needed.

Rescue treatments for hormonal headache pain

Becoming aware of the timing of your hormonal headaches or migraines can certainly help you decrease their frequency with preventative measures, and we encourage you to read our article on chronic headaches, particularly the section on migraines, to learn more about migraine patterns and theories. Nevertheless, even women who adopt the healthiest lifestyle and dietary habits and hormonal–balancing measures can get the occasional painful migraine. Life is full of stressors and you can’t be on top of all of them all the time! When hormonal headaches and migraines arise acutely despite our best efforts, prompt implementation of rescue treatment measures as early as possible will deliver the most effective relief.

When worse comes to worst, there are a few rescue meds that can be useful to have in your medicine chest. Use these with caution: take only as directed, and never use any drug without discussing your lifestyle and other prescriptions with your practitioner first.

• NSAID’s. Nonsteroidal anti-inflammatories (NSAID’s) can be particularly helpful if used early and at a dose optimal for you. I suggest ibuprofen (brand names Advil or Motrin) with food, up to 800 mg every 4–6 hours, no more than two days in any given week (max is 2400 mg per 24-hour period). However, some women really respond well to plain old-fashioned aspirin, and some to Excedrin Migraine, which contains acetaminophen, aspirin, and caffeine.

If you are in the habit of taking NSAID’s, please read the section of our chronic headache article on avoiding rebound headaches. If you are trying to conceive or are pregnant, acetominophen (aka paracetamol, or brand name Tylenol) is the only recommended choice in the NSAID category, to protect the safety of the fetus/baby. Ibuprofen and aspirin can cause birth defects and other serious problems with your growing baby, so be sure to discuss with your midwife or obstetrician before using any medications. Fortunately for hormonal headache sufferers, pregnancy is often a time of reprieve.

• Triptans. These are antimigraine agents that are believed to work by binding to serotonin receptors in the brain to constrict blood vessels and reduce inflammation. Some headache experts suggest that women who observe that their migraines or debilitating headaches occur predictably on certain days, e.g., day 1 or 2 of menses, take a triptan once or twice a day on those days as prophylaxis. Although this usage has not been formally approved by the FDA, you can certainly ask your headache specialist about this.

Triptans such as Frova, Imitrex, and Relpax are newer triptan pain formulations with long-acting effect. Again, they work best when taken as close to the migraine onset (prodrome) as possible. If one triptan doesn’t work well for you or you had side effects, another formula may be better — so don’t despair. Every woman is different and each has an individual response; it may just take time to figure out the right solution for you. Triptans are not advisable for use in pregnancy, and must be used with extreme caution if also on an SSRI antidepressant.

• Other prescription migraine treatments. For a complete list of migraine treatments used in conventional clinical settings, visit the website of the National Headache Foundation. Many of these treatments were developed to address other medical conditions, such as heart disease, high blood pressure, depression, congestion, and so on, but were coincidentally found to abort the acute pain of migraines. In some cases, they are used in combination and as a preventative and a therapeutic. All of these drugs must be taken under strict medical supervision. If you are currently taking any of these medications, it is still safe to consider all of the other natural measures we’ve discussed above.

As headaches are so often multifactorial, we also suggest you review our list of ten ways to eliminate chronic headaches naturally. Implementing these practices, too, will certainly contribute to the wellbeing of any woman who suffers from hormonally-driven headaches and migraines. Hopefully, with time, you will find yourself relying less and less on a heavy-duty pain-reliever and increasingly on your body’s innate wellness mechanisms.

Balanced and pain-free

While headaches may seem to be “all in your head,” the most effective treatment for any health problem takes into account the needs of the whole body. Unlike conventional medicine which only treats the pain, an integrative approach restores the body’s baseline ratio of hormones. If you and your practitioner think your hormones are causing your headaches, that may actually be a good thing, because it means that a wealth of opportunity exists for you to take proactive measures.

By focusing on core nutrition, proper supplements, and a healthy lifestyle, with careful use natural hormonal support when needed in times of change, you can decrease both the frequency and intensity of your hormonal headaches. You may even find that other symptoms dissipate as well. This bottom-up approach may require you to invest a few months before you notice significant improvement. But once you get there, you may find yourself completely free of your headaches — and your back-up pain-relievers!

NOTE: Severe, blinding pain that comes on suddenly with no prior migraine history should be taken seriously. If you are experiencing new or different headaches, severe headaches, or headaches with associated sensory or neurological symptoms, seek immediate help at your local emergency department. DO NOT WAIT.

 

Original Publication Date: 09/14/2006
Last Modified: 02/16/2010
Principal Author: Marcy Holmes, NP, Certified Menopause Clinician