Migraine affects over 1 billion people worldwide and is more common in females than males, particularly in those of reproductive age—15 to 49 years old. Experts attribute the cause of migraine in females to a complex interaction of factors, including sex hormone changes, psychological/social influences, environmental triggers, and genetics.

1. Sex Hormones

Migraine is 2 to 3 times more common in females than males. Females report more prolonged migraine attacks, a higher likelihood of headache recurrence, and a longer recovery period. Sex hormones that are typically higher in people with ovaries, namely estrogen, are significant in accounting for these differences.

Menstrual Migraine

Menstrual migraine is a migraine attack that manifests in relation to the menstrual cycle. Compared to non-menstrual migraines, menstrual migraines tend to last longer and are more severe and resistant to treatment.

Types of menstrual migraines include:

• Pure menstrual migraine: Migraine attacks that occur only during what is referred to as the perimenstrual stage, which starts two days before the start of menstrual flow and ends three days after the start of menstruation.
• Menstrually related migraine: Migraine attacks that occur during the perimenstrual state but can also manifest outside of menses.

The most significant factor linked to the development of menstrual migraine is the drop in estrogen that occurs just a few days before menstruation.

Estrogen is believed to interact with several brain chemicals, such as serotonin, dopamine, endorphins, and oxytocin. These chemicals play various roles in suppressing pain and regulating the release of inflammatory substances, like calcitonin gene-related peptide (CGRP) within the brain.

It’s believed that when estrogen levels drop just before menstrual flow, the delicate balance of the brain chemicals is altered, triggering a migraine attack in those who are migraine-prone.

Notably, estrogen also has receptors (docking sites) on trigeminal nerve fibers, which are responsible for releasing CGRP. Perhaps trigeminal nerve fibers are sensitive to alterations in estrogen levels.

Perimenopause

Perimenopause is the time leading up to menopause (cessation of menstrual periods) when estrogen levels increase and decrease irregularly. The variable estrogen levels can cause worsening migraine, along with irregular periods, hot flashes, breast tenderness, and mood and sleep disturbances.

Interestingly, migraine attacks tend to diminish in menopause, the time of life when a female stops menstruating for 12 months in a row.

In menopause, a woman’s estrogen levels are stably low, not variably changing, further supporting the link between unstable estrogen levels and migraine manifestation.

Hormonal Birth Control

Hormonal birth control (such as the birth control pill) is another potential cause of migraine headaches in females of childbearing age.

Among females taking hormonal contraception:

• 18% to 50% reported a worsening of migraine
• 3% to 35% reported an improvement of migraine
• 39% to 65% reported no change in the number of migraine attacks

Migraine worsening tended to occur more often in people taking combination birth control pills in the traditional 21-to-7 cycle. Combination birth control pills—commonly called “the pill”—release estrogen and progestin (a synthetic version of the hormone progesterone) into the body.

In contrast, migraine improvement was more often reported in those taking progesterone-only birth control or combination birth control pills in the long-term cycle.

These findings support the theory that sudden changes or drops in estrogen, as opposed to more gradual changes, increase the risk of migraine.

2. Psychological and Social Factors

Experts suspect that psychological and social stress likely contribute to migraine vulnerability, especially in women of reproductive years.

Females report stress more than males as a migraine trigger. Women of reproductive age often juggle multiple stressors, such as having and caring for children, building professional careers, and navigating complex relationships, both socially and at work. These demands may result in fatigue or anxiety, heightening the risk of migraine attacks.

3. Environmental Triggers

Outside, or environmental, factors are known to trigger migraines. These triggers signal the brain to undergo changes in blood vessels and inflammation that cause a migraine attack.

Common migraine triggers for females include:

4. Genetic Influences

Genetic factors also play a pivotal role in migraine development. If one or both parents experience migraine attacks, there is a 50% to 75% chance their child will.

For most migraine types, a person must inherit one or more “migraine genes” and be exposed to something within the environment (e.g., hormone fluctuations, stress) for the migraine disorder to manifest.

So far, 171 single-nucleotide gene polymorphisms (SNPs) linked to migraine have been discovered. SNPs are changes in the DNA sequence of a gene.

5. Pain Threshold

Research has also found that among people with migraine, females have a lower pressure pain threshold than males. This increased pain sensitivity may make females more vulnerable to migraine attacks.

Preventing and Managing Migraines in Females

A combination of medication and lifestyle behaviors is used in the management of migraine. Prevention and treatment regimens are uniquely tailored and based on factors like an individual’s migraine triggers, migraine characteristics (e.g., severity), and medication response or tolerance.

Acute Medication

Mild migraine headaches can often be alleviated with a nonsteroidal anti-inflammatory drug (NSAID) like Aleve (naproxen sodium) or Advil and Motrin (ibuprofen).

Severe or persistent migraine headaches usually necessitate a triptan, a prescription drug that binds to specific serotonin receptors in the brain.

For those who cannot take a triptan, alternatives such as Tylenol (acetaminophen), a calcitonin gene-related peptide (CGRP) blocker such as Ubrelvy (ubrogepant), or a serotonin receptor agonist such as Reyvow (lasmiditan) might be considered.

Preventive Medication

People who experience frequent and debilitating migraine attacks or who do not obtain sufficient relief from the therapies mentioned above may be candidates for preventive medication.

Particularly in people with regular menstrual migraines, one preventive strategy is taking a medication one to two days before menstruation begins and then continuing it for around five more days.

Short-term preventive medications typically used for menstrual migraines include:

• An NSAID
• A triptan, such as Frova (frovatriptan) or Zomig (zolmitriptan)

Hormonal contraception is another option for menstrual migraines because it can help keep estrogen levels relatively stable in the body.

Hormonal options include:

• Continuous dosing (no week off) of combination birth control bills or vaginal rings, such as NuvaRing or EluRyng (etonogestrel/ethinyl estradiol vaginal ring)
• Combination birth control pills that contain very low or low doses of estrogen (10 to 30 micrograms)
• Extended combination birth control pills (91-day regimens)

For people experiencing worsening migraine in perimenopause, hormone replacement therapy or the antidepressants Prozac (fluoxetine) or Effexor (venlafaxine) are preventive medication options.

Another preventive strategy for any migraine type, including menstrual/estrogen-related migraines, is taking daily nonhormonal medication. There are multiple types of migraine preventive drugs.

Examples include:

• The anti-seizure (anticonvulsant) drug Topamax (topiramate)
• The beta-blockers (a type of high blood pressure drug) Inderal LA (propranolol) or Blocadren (timolol)
• Calcitonin gene-related peptide (CGRP) blockers such as Aimovig (erenumab), Ajovy (fremanezumab), and Emgality (galcanezumab)
• Botox (onabotulinumtoxinA) injections

Lifestyle

Lifestyle habits also play a vital role in migraine prevention. They include avoiding triggers like skipping meals or not getting enough sleep.

It can also be helpful to journal when your migraine headaches occur, how long they last, and the accompanying symptoms.

Lastly, if a person experiences unpredictable menstrual migraines, their provider may advise a magnesium supplement. The recommendation usually is to take magnesium 15 days after the start of their period and continue it until their next period begins.

When to See a Provider

Most migraines are not dangerous. In rare cases, though, serious complications may develop, such as seizure, stroke, or status migrainosus (a migraine that lasts 72 hours or longer).

Go to your nearest emergency room or call 911 if you are experiencing the following during or after a migraine:

• Stroke symptoms like weakness on one side of the body or difficulty speaking
• Convulsions (twitching or jerking that is out of your control) or loss of consciousness
• A migraine lasting more than 72 hours

You should see a healthcare provider, such as a neurologist or other headache specialist, if you experience the following symptoms:

• Your migraine attack pattern is changing—for example, occurring more frequently or becoming more severe.
• You are experiencing rebound migraine headaches caused by the overuse of pain medication.
• You develop a migraine while pregnant or after delivery.
• You have a suppressed immune system or are 65 years old or older and have migraines (or other headaches) that feel different from those in the past.
• Your migraine (or other headaches) are triggered by sneezing, coughing, or exercise)

Getting a Specialist Referral

A few ways to obtain a headache specialist referral are:

• Ask your primary care provider or obstetrician-gynecologist (ob-gyn) for a referral to a neurologist with experience treating migraine and headache disorders.
• Search for a specialist through the American Migraine Foundation online database.
• Migraine support groups, such as the Facebook group Move Against Migraine, may also provide guidance on finding the right provider for migraine care.

Summary

Migraine is more common in females. Migraine attacks in females also tend to last longer and be more severe and disabling compared to males.

These differences are attributed mainly to the natural fluctuation of the hormone estrogen. Cyclical changes in estrogen can cause menstrual migraines. Erratic fluctuations of estrogen levels before menopause can trigger or worsen migraine headaches.

Other causes of migraine (in people of all sexes) include environmental, psychological, social, and genetic factors. Females may have a lower pressure pain threshold than males, and they report stress and bright lights as migraine triggers more often than males.

Prevention and management of a migraine headache involves a combination of medications, either hormonal or nonhormonal, and lifestyle habits, such as minimizing triggers. Seeing a neurologist is particularly vital for people experiencing frequent or disabling migraines that aren’t responding to typical therapies.