MENSTRUAL MIGRAINES
Photo credit: The Sleeping Girl (Kizette) by Tamara de Lempicka, 1933
I’ve been very lucky (knock on wood!) I have only experienced rare headaches here and there in my life, but in the last couple of years I’ve become aware of how prevalent they are in women, especially in connection to sex hormone fluctuations during the reproductive years.
In fact, according to the American Migraine Study II, the prevalence of migraines is approximately 18.2% in females and 6.5% in males. The female to male prevalence ratio is 2:1 at 20 years of age, and 3.3:1 between ages 42 and 44! The incidence of migraines begins to rise after the onset of menstruation, and is most prevalent in middle age women. Many women also experience migraines during pregnancy, a time of significant hormonal changes. The incidence decreases slightly for women in the menopausal years.
Menstrual migraines refer to migraines that are temporarily related to menstruation, they occur at any time of the cycle with increased frequency during menstruation. The term True Menstrual Migraine (TMM) is defined as migraine that occurs specifically about two days before menstruation and on days one to three.
Menstrual migraines are believed to be related to estrogen and progesterone fluctuations, and their interrelated neurotransmitter changes. Three possible causes:
A drastic drop in estrogen during the luteal phase of the cycle (the phase that starts right after ovulation and ends with menstruation), especially for women who have elevated estrogen during the follicular phase (the phase between menstruation and ovulation), has been shown to cause migraines.
Having low progesterone during the luteal phase is also associated with migraines. This is even more common for women in the perimenopausal stage (also referred to as the period of time transitioning to menopause, which can last for years before its onset).
The rise in inflammatory compounds called prostaglandins, which occurs shortly before menstruation. These compounds may trigger the nervous system inflammation that causes headaches in some women.
If you’ve identified that your headaches are in fact connected to hormonal fluctuations, working to balance estrogen and progesterone, and improving estrogen metabolism and excretion, can make a huge difference.
Here are some strategies that may help…
Identify your particular triggers. Even slight dehydration can lead to a migraine. Specific foods and scents can exacerbate them as well. Keeping a migraine journal can help you identify your particular triggers. Common food triggers include foods that are high in histamines. Some high histamine foods include:
Aged cheese, buttermilk, kefir
Shellfish and canned, smoked, or fermented fish
Smoked, cured, or processed meat, including salami, sausage, and deli meats
Fermented vegetables including sauerkraut
Nuts, especially cashews and walnuts
Legumes, especially chickpeas
Very ripe fruits like bananas, and avocados.
Vinegar and any foods made with vinegar, such as pickles, ketchup, or relish
Alcohol, including wine and beer
Canned foods
Coffee
Food additives: benzoate, sulfites, nitrites, glutamate, food dyes, and any other preservatives or artificial colorings
2. Know your particular hormonal profile. It’s key to finding the most helpful treatment plan. Detailed cycle tracking will help you find patterns and give you more information to consult with your doctor or health practitioner for the most individualized and effective protocol. I’m a big fan of using a type of FAM–Fertility Awareness Method–that tracks more than just bleed days, one that includes basal body temperature monitoring, and tracking of cervical mucus changes. FAM is more than a fertility/birth control tool, it’s a window into your own particular hormonal rhythms, which affect your overall health. It can help you figure out if you’re consistently ovulating, and give you and your doctor more clues as to what hormones may be off balance. There are so many cycle tracking apps these days to help keep track of all the information you gather throughout each cycle.
3. Optimize estrogen metabolism to avoid/improve estrogen dominance. The liver is in charge of hormone metabolism and excretion. You can support it by consuming cruciferous vegetables regularly, broccoli sprouts are especially helpful. Also, our liver has an affinity for the bitter flavor- think dark leafy greens. You can also experiment with adding 1-2 tablespoons of flax and/or chia seeds to meals daily to help regulate estrogen. Make sure to consume at least 25g of fiber daily, and to have daily bowel movements for proper excretion of excess hormones.
4. Keep blood sugar levels steady. I can’t stress how important this is for hormonal health! Elevated blood glucose and insulin resistance trigger inflammation, increasing the pro-inflammatory prostaglandins that can cause migraines. Beyond avoiding sugar and refined carbohydrates, eat protein with every meal, and eat it first, carbohydrates last. Focus on foods high in fiber. Fiber slows down the absorption of foods in order to maintain more stable blood sugar throughout the day, and avoid snacking on “naked” carbohydrates to prevent blood sugar spikes.
5. Stress management, sleep, and exercise. Cortisol is the stress hormone that may cause elevated blood sugar. Learn how to identify when your body is in stress mode (sometimes we stop noticing!), and how to activate the parasympathetic nervous system (the relaxed, calm state) with breathing exercises. Also, a consistent bedtime routine and natural light exposure during the day can help improve sleep. As far as exercise goes, while moving our bodies daily helps reduce migraines, avoiding high intensity exercise during stressful times may be necessary to prevent us from getting stuck in the stress-response mode.
6. Key Nutrients/Supplements that have been found to be helpful in the treatment of menstrual migraines. Vitamin B2, B6, B12 and methyl folate, Vitamin D, Calcium, Magnesium, CoQ10, Essential Fatty Acids (note that it can take at least one month to see results).
7. Herbal support. Here are some botanicals to look into but please note that most herbs are contraindicated in pregnancy, and many during lactation too. Also some herbs may have interactions with medications, so check carefully with your doctor. Feverfew and Butterbur–these anti-inflammatory herbs have been found to be specifically helpful in preventing migraines. Also Curcumin, especially when combined with CoQ10 and Omega 3 fatty acids. Ginger (dried form) is another one, and consider taking digestive bitters a few minutes before meals for gut and liver support. If stress is a main migraine trigger for you, look into herbs in the adaptogen category (i.e Ashwagandha, Rhodiola, Eleuthero, Reishi, Schisandra, Holy Basil…).
REFERENCES
R.B. Lipton, W.F. Stewart, S. Diamond, M.L. Diamond, M. Reed. Prevalence and Burden of Migraine in the U.S.: Data from American Migraine Study II. https://pubmed.ncbi.nlm.nih.gov/11554952/. 2001
E.A. MacGregor, A. Frith, J Ellis, L Aspinall, A. Hackshaw. Incidence of migraine relative to menstrual phases of rising and falling estrogen. https://pubmed.ncbi.nlm.nih.gov/16971700/. 2006
S.D. Silberstein. Sex Hormones and Headache. https://pubmed.ncbi.nlm.nih.gov/11139745/ . 2000
Romm, Aviva. 2nd ed., 2018. Botanical Medicine for Women’s Health. Elsevier Inc. p.p. 224-235.