Menstrual migraine: why you get more attacks around your period

Menstrual migraine is migraine linked to the hormonal changes of your menstrual cycle. The main trigger is the fall in oestrogen in the days before your period, which makes the brain temporarily more sensitive. Period migraine attacks are often longer and harder to treat, but there is more you can do than you might think.

Every month the same pattern: a few days before or during your period you feel it coming. The restlessness, the tiredness, and then that familiar throbbing headache. If you feel your migraine is connected to your cycle, you are probably right.

What is menstrual migraine?

Menstrual migraine, often called hormonal migraine, is a form of migraine linked to the hormonal fluctuations of your menstrual cycle. It is one of the most common forms of migraine in women. Migraine specialists distinguish two forms:

• Pure menstrual migraine: attacks occur only around the first day of your period.
• Menstrually related migraine: attacks also occur at other times, but are clearly more severe or more frequent around your period.

Your period itself is not the cause. Migraine is an inherited brain condition. The hormonal change is a trigger that can set off an attack in women who are predisposed to migraine.

What are the symptoms of menstrual migraine?

The symptoms are similar to those of other migraine attacks, but a few features stand out:

• Throbbing, one-sided headache, often more intense than at other times
• Longer attacks: menstrual migraine attacks last longer on average than non-hormonal ones
• Nausea and sometimes vomiting
• Sensitivity to light and sound (photophobia and phonophobia)
• Harder to treat: acute medication sometimes works less well

Not everyone has all of these symptoms. Migraine is individual, and your pattern may be different from someone else's.

Why do I get migraines during my period?

In the days before your period, the fall in oestrogen changes the stability of your brain. It becomes more sensitive to stimuli: stress, lack of sleep, bright light or even a smell can then be enough to trigger an attack.

This mechanism resembles what is seen in epilepsy, another neurological condition in which the brain's electrical balance is disturbed. The World Health Organization counts migraine among the leading causes of disability worldwide, and migraine affects women about three times as often as men. Hormones play a large part in that difference.

What can you do about hormonal migraine?

Recognise your pattern

Keeping a headache diary is the first step. For at least three months, note when your attacks happen in relation to your cycle. Many women believe more strongly in a link between migraine and their period than the facts support, and a diary shows what is really going on.

Treating the attack

Triptans are often effective for menstrual migraine attacks, especially when taken early. Because these attacks can last longer, a migraine specialist can help you plan how to treat them, including whether a different triptan suits you better.

Preventive treatment

If you have frequent attacks, preventive treatment is an option. Our migraine specialists can prescribe the gepants atogepant and rimegepant, which are used for both acute treatment and prevention, and the monoclonal CGRP inhibitors erenumab, fremanezumab and galcanezumab. These medicines were developed specifically for migraine and can also work in hormonal migraine. Other preventive options exist; your GP can discuss them.

It is also important to watch out for medication overuse: taking acute medication too often can make migraine worse.

Contraception and the combined pill

The combined contraceptive pill is sometimes used to even out hormonal fluctuations. With the classic regimen (three weeks of pills, then a week off), oestrogen falls during the pill-free week, and that fall can trigger migraine. We now know the pill-free week is not medically necessary. Taking the pill continuously reduces the fluctuations and can bring relief from menstrual migraine.

Please note: women who have migraine with aura have a higher risk of blood clots, including stroke, when taking the combined pill, especially if they smoke. Always discuss contraception with your GP or a sexual health clinic. We do not prescribe hormonal treatment ourselves.

The hormonal coil (IUS)

Another option is the hormonal coil, also called an intrauterine system (IUS). It releases hormone locally, which can make periods much lighter or stop them altogether. Many women with migraine report improvement after having one fitted. The scientific evidence is limited, but experiences are positive. Your GP or a sexual health clinic can tell you whether it suits you.

Does menstrual migraine change during pregnancy?

Many women with migraine notice a clear fall in attacks during pregnancy. Hormone levels are then relatively stable, without sharp peaks and falls in oestrogen. After the birth the fluctuations return, and the migraine often does too.

Is hormonal migraine only about your period?

Although oestrogen is the best-known hormonal trigger, other hormones also play a role. Research points to a possible influence of oxytocin on migraine attacks. And some women still have migraine long after the menopause, when oestrogen is low but stable. Migraine is more complex than hormones alone.

Does menstrual migraine stop after the menopause?

For some women migraine improves after the menopause, but not for everyone. The years around the menopause are often an unstable time with more attacks, because hormone levels fluctuate unpredictably.

Getting help with menstrual migraine

About 10 million people in the UK live with migraine, and many wait years before they get the care they need. At The Migraine Clinic a migraine specialist looks with you at the role hormones play in your migraine and what you can do about it, by video and without a referral. Want to know whether your symptoms fit menstrual migraine? Take the migraine test, or read more about acute medication and preventive medication.

Written by the medical team of The Migraine Clinic.