Estrogen: Friend or Foe for Women with Migraine?

As a physician practicing women’s health for many years, I am tired of the “bad rap” that estrogen has received in the media in recent years. I am also dismayed by the negative attitude of many physician colleagues, including gynecologists, who are hesitant to treat women migraine patients with estrogen including estrogen-containing birth control pills. While there may be a very slight increase risk of stroke in migraine patients compared to the general population, that risk is very small and often blown out of proportion. The theoretical concern of increasing stroke risk by putting a female migraine patient on estrogen needs to be balanced against the many potential benefits of estrogen for women.

Benefits of estrogen-containing contraception are many and include:

  1. Prevention of disabling menstrual migraines if taken continuously, thereby preventing the drop in estrogen that is the most common trigger for menstrual migraine
  2. Relief of premenstrual symptoms including mood changes, bloating, and cramping. Some birth control pills are FDA approved for Premenstrual Dysphoric Disorder (PMDD) such as Yaz (now available as a generic). PMDD is a common co-morbid condition with migraine.
  3. Relief of painful menstrual cramps, heavy periods, irregular periods
  4. Relief of acne
  5. Birth control that is highly effective
  6. Treatment of endometriosis
  7. Relief of perimenopausal symptoms including hot flashes, night sweats, insomnia and irregular menses that characterized this time in women’s life

The amount of estrogen in birth control pills used to be as high as 80 micrograms (mcg) of ethinyl estradiol. Current dosages are much lower and are typically 20-35 mcg of ethinyl estradiol (EE). Therefore, studies showing risks of birth control pills need to be looked at in terms of the dose of estrogen being taken as well as the specific product being studied.

When deciding on the risk versus the benefit of prescribing an estrogen-containing birth control pill for a woman with migraine I feel that the following risk factors need to be looked at:

  1. Smoking
  2. Uncontrolled High Blood Pressure
  3. Personal or Family History of Clotting Disorders
  4. Obesity
  5. High Cholesterol

If these risk factors are not present then I feel that most women with migraine can safely be allowed to take an estrogen-containing birth control pill. This is especially important if they need birth control. Given that 50% of pregnancies are not planned and that migraine peaks in women of child-bearing years, then the issue of contraception is critical.

Most health care providers are not comfortable with any form of estrogen in women who have migraine with aura. In my opinion, women with aura should not all be clumped together. There is a big difference in women who have occasional aura and no other risk factors for stroke versus a woman with frequent aura and other risk factors. I have many women who rarely have aura, have no other risk factors for stroke, and have a strong desire to be on an estrogen-containing birth control pill for either birth control or for another medical reason such as to control their painful and/or heavy periods. I usually will allow these women to go on a birth control pill like Yaz or Yasmin and then carefully follow them. If they report an increase in aura or migraine then I re-evaluate our plan and may take them off estrogen. The majority do fine!

Estrogen: friend or foe of the female migraineurs? In most cases, I vote for FRIEND! What do you think?

This article represents the opinions, thoughts, and experiences of the author; none of this content has been paid for by any advertiser. The Migraine.com team does not recommend or endorse any products or treatments discussed herein. Learn more about how we maintain editorial integrity here.

Comments

View Comments (9)
  • stardustizme
    4 years ago

    Let me start off with, I am extremely happy I found this site. I have been suffereing from migraines for as long as I can remember, my first actual memory of one was when I was 9 year old. My migraines always have aura with them. I have failed all medication groups and now trying botox, only a week and a half in.
    Currently I feel like I am at war with my doctors over estrogen. My general practitioner, who was unaware of the stroke risk at the time, put me on a generic of Sprintec and since taking it, for four months, my migraines have gone down the week before my period and none during my period. I also had a ton of other benefits from the estrogen. The issue is, I saw my neuroligist and general doctor neither of them said anything about a risk of stroke. Yet when I went to get the botox injections, I was informed that I should not be on it at all since I smoke and I have migraines with aura (which I am willing to quit if I can stay on estrogen). So I was switched back to proestrogen and in the past its only given me more headaches and two cycles a month. Within the first two days of taking it I am already having more migraines with more aura then normal. The week after my cycle I should not be getting any migraines unless I am stressed out which I have not been. At this point I am trying to find out from other sources if the lack of estrogen and increased of proestrogen is causing more of my migraines or not. Are there any tests I can ask my doctor to perform or any other things they should be looking at? Migraines have already taken a lot of my life way and I felt like I was finally getting them under control! HELP!

  • stardustizme
    4 years ago

    I would also like to add, most medications I am on, I tend to have opposite negetive reactions. Sometimes the more rare ones too. I’ve tried all the main preventives and few “lets just try and see” with absolutely no results. the most results I had was on estrogen.

  • sheepwriter
    8 years ago

    Interesting stuff here. I didn’t start having migraines until I was in my late 40s, so I didn’t realize for a while that the horrendous and disabling pain I was suffering was migraines. Dr. did all the requisite stuff like MRI, CAT, blood work, etc and started me on amitriptyline. We gave it a good long while to work, but it didn’t help and migraines got worse and more frequent.

    After trying numerous (and ineffective) preventatives, I surmised that menopause and the associated change in hormones was likely the cause. The easy answer to me was HRT, but there’s a strong family history of breast cancer in my family (several first degree relatives with onset under age 45). Dr was very reluctant to start HRT, but finally agreed that it was a quality of life issue and put me on low dose HRT. What a miracle that was! Migraine frequency went from several a week to several a month. Wow. I had a life again.

    I’ve stopped taking the HRT and the migraines are back (not as frequent, but just as severe). If that isn’t proof that some migraines are hormone-associated, nothing is.

  • Dr Hutchinson author
    8 years ago

    Women are often desperate to get “everything taken” including uterus and ovaries in an attempt to no longer have any menstrual periods and hormonal fluctuations that are common triggers for migraine. However, women that have “everything taken out” often have a difficult time as you did. This abrupt “taking everything out” can make migraines worse due to abrupt drop in hormones. Some women can then wear an estrogen patch such as Vivelle (estradiol) as “add-back” estrogen; others find that any estrogen aggravates their migraines. For protection against osteoporosis for those women who can’t tolerate “add back estrogen” there are other treatments available for including adequate calcium and weight-bearing exercise; if osteopenia or osteoporosis are present, then biphosphonates such as Fosamax and Boniva are helpful.

  • Ellen Schnakenberg
    8 years ago

    I’m one of those who had terrible Migraine with aura during pregnancy, although my first Migraine and aura did occur a few years prior to that. I found personally, that eliminating estrogen through Zoladex treatments for nearly a year, followed by hysterectomy and oopherectomy, was horrible. Adding a small consistent dose of estrogen (via patch, not pill) could mostly keep Migraines at bay. However, because my surgery was needed in part to eliminate estrogen, it was out of the frying pan and into the fire. We tried hard to find a “sweet spot” that wouldn’t trigger further estrogen related problems yet keep my Migraine and other headache issues survivable. Eventually, estrogen began to actually cause much of my trouble, so I finally had to relent and stop all hormone treatment. I’m told this likely occurred as a result of changes in estrogen receptors.

    My doctor now wants me on a small amount of estrogen because of my ‘young’ age and history of osteoporosis and other issues.

    Gee, when I need it, I can’t have it. Now that my body doesn’t want it, I’m supposed to take it. What’s a girl to think?

  • Dr Hutchinson author
    8 years ago

    Women who have migraine with aura are much more likely to feel that estrogen is the culprit for their migraines as opposed to women who have migraine without aura who often feel that estrogen, when kept at an even level, helps their migraines, especially their menstrual migraines. This difference is demonstrated in looking at the effect of pregnancy on migraine. During pregnancy, estrogen levels rise dramatically and then remain at a fairly even high level until delivery. The majority of women without aura have marked improvement in their migraines during pregnancy in contrast to women who have migraine with aura. Migraine with aura may worsen during pregnancy and may be from the high levels of estrogen. Additionally, migraine may occur for the first time during pregnancy and when it does, it is usually migraine with aura.

  • rebekka4684
    3 years ago

    This is by far the most useful statement I’ve come across explaining the differences and likelihood of hormonal migraine for people dealing with migraines with/wo aura.Thank you! I was close to getting an IUD but now I changed my mind. Been on a combination pill for many years and try to take it for 3 months at a time. I don’t have auras but have been feeling ‘off’ – my guess was the estrogen but now I’m not so sure.

  • hurleygirly
    8 years ago

    I suffer from migraines with auras and I can say that in my case, I believe estrogen is my worst enemy and should never have thought it to be ok for me when prescribed by my physicians. My migraines started when my period started which tells me it had something to do with my hormones. No matter what birth control pill I was on, my migraines came often and were so bad, I would consider them “mini strokes”. My mother has the same type of migraine and was told to never attempt any form of birth control pill. This past year I was diagnosed with breast cancer which was 95% estrogen sensitive and there is definitely some controversy as to whether or not birth control pills played a role. In my opinion, estrogen seems to be the culprit for whatever health issue is thrown my way!

  • Diana-Lee
    8 years ago

    I think the most important thing is to keep our estrogen levels at a standard level if at all possible. Hormone fluctuations are such a problem for migraineurs. While it is important to be aware of the stroke risk, I do think it is a very slim chance and shouldn’t keep us from trying necessary treatments.

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