Migraine and Hormones

Migraine headaches affect both sexes equally until puberty while they are more prevalent in women after puberty and the frequency, duration, and intensity of the attacks are increased. Migraine headaches are three times more prevalent in women than men at the age of 30 years. Peri-menopausal and peri-pubertal periods are associated with increased risk of migraine headaches, most probably due to female sex hormones and estrogen level fluctuations.Steady or rising concentrations of estrogen do not precipitate migraine; however, falling estrogen levels in the late luteal phase is supposed to be the most potent trigger of migraine. Estrogen withdrawal causes an oxidative stress, reduced production of serotonin, increased sensitivity to prostaglandins and a release of neuropeptides such as calcitonin gene-related peptide (CGRP), substance P and neurokinins . Endogenous opioid activity also decreases at low estrogen levels. The levels of CGRP, are reported to be higher in women of reproductive age than in men and cyclic hormonal fluctuations influence CGRP release.OCPs, when used for the first time, have different effects on migraine headaches. It may increase the frequency or intensity of headache or change its characteristics. Current evidences are against the use of combined hormonal contraceptives in women with migraine with aura and in women with migraine without aura who have additional cardiovascular risk factors, like smoking, arterial hypertension and previous history of a thromboembolic event. In women with migraine without aura who have no additional risk factors, monophasic OCPs containing <20mcg EE can be used as contraception, with monitoring of migraine frequency and characteristics. Progesterone-only pills appear to be safe in migraine as they do not induce migraine, and may reduce migraine attack frequency and intensity.HRT in migrainous women should be administered according to its common indications and contraindications, even in migraine with aura. Continuous HRT with estrogen with or without progesterone in women with a healthy uterus is preferred.