How Are Menstruation, Birth Control, and Migraine Connected?

January 26, 2024
August 8, 2021
How Are Menstruation, Birth Control, and Migraine Connected?

More than 60% of women report an association between their periods (menses) and migraine attacks. However, that association is not always obvious for two reasons: 

  1. The migraine attacks associated with menses occur between 2 days before the onset of bleeding and up to the 3 first days of bleeding. Some women have a severe migraine attack 2 days before the onset of bleeding, so it can be hard to note the association.
  2. There might be a lot of variation between menses and migraine attacks in some women. Some women have irregular cycles that are hard to predict. Some of the cycles do not come with a migraine attack even if there is an association for most cycles. 

Tracking your migraine attacks on the Neura Health app for at least 3 months is helpful to assess the relationship between your migraine symptoms and menstrual cycle. 

Why do we care to know whether your menses are associated with migraine? 

  1. Migraine attacks related to menses tend to be more severe and harder to treat. They need to be discussed with your doctor. 
  2. There are ways to help. To date, there are no acute treatments specifically for those attacks. The same acute treatments are used for migraine attacks related to menses and unrelated to menses. However, what we call “mini-prevention” can help for the menstrual-related migraine attacks. Mini-prevention means taking longer acting triptans such as frovatriptan, NSAIDs, or gepants on a regular schedule for the few days of expected menstrual-related migraine attacks. Your headache doctor might also discuss with you and your gynecologist whether continuous birth control might be an option for you. The idea behind taking continuous birth control would be to have stable levels of sex hormones and hence less migraine attacks.  We will discuss this at more length below.  

Migraine and Birth Control

Migraine attacks might be associated with your menses whether you take birth control pills or not. The placebo pill of birth control does not contain estrogen, so there is a drop in your estrogen levels at the end of your period, which might trigger migraine. If you develop new or worsened migraine attacks around your menses after starting combination birth control (estrogen and progesterone), discuss other birth control options with your doctor.

Another important thing to know about birth control and migraine is that estrogen containing birth control slightly increases stroke risk, especially in women with migraine with aura. The risk of stroke in women of reproductive age is low at 3.56 strokes per 100,000 women. That risk is twice as much in women with migraine in general. It is higher in women who have a diagnosis of migraine with aura. 

Migraine aura refers to neurological symptoms that gradually progress over the course of 5 to 60 minutes before a headache attack. The symptoms can be vision changes, tingling, speech difficulty, weakness, and dizziness for example. The stroke risk in women of reproductive age with migraine with aura is estimated between 18 and 40 strokes per 100,000 women. The stroke risk increases even further when taking estrogen containing medications. The increased stroke risk depends on the dose of estrogen. The higher dose of estrogen taken, the higher the stroke risk. For this reason, most doctors will not recommend estrogen as part of a birth control plan for people who experience migraine with aura. 

Non-estrogen containing birth control is preferred in women with migraine with aura - and many options are available for you. It’s important to note though, that smoking is associated with an even higher risk for stroke, and is a special contraindication to estrogen containing birth control, even more so in women with migraine with aura. 

In summary, it is important to keep track of your migraine attacks to evaluate whether they are associated with your menses. Since menstrual-related migraine attacks tend to be more severe and harder to treat, a specific plan to deal with them should be discussed with your doctor. If you have migraine with aura, please be sure to let your provider know when discussing birth control options as estrogen containing birth control would increase your risk of stroke. 

If you are looking for a convenient way to track your migraines, discuss them with a professional neurologist and get treatment, join Neura Health and start your journey to relief today!

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Olivia Begasse De Dhaem, MD
Dr. Olivia Begasse de Dhaem is a board-certified and fellowship-trained neurologist and headache specialist, and an Advisor to Neura Health.
About the Author
Dr. Olivia Begasse de Dhaem is a board-certified neurologist and Headache Specialist at Hartford HealthCare in Milford CT. She graduated from Columbia University College of Physicians medical school. She attended her neurology residency at the Columbia University Neurological Institute. She completed her headache medicine fellowship at Harvard University. She is an emerging leader of the American Headache Society. She is involved in advocacy and feels strongly about supporting people with headache disorders in the workplace.

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