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Menstrual (Hormonal) Migraine

Reviewed by: HU Medical Review Board | Last reviewed: October 2020

Changes in estrogen levels can trigger both migraines and headaches. Migraines of this type are called menstrual or hormonal migraine and may happen with aura or without. Menstruation, pregnancy, menopause, birth control, and in vitro fertilization are the most common triggers of this type of migraine.1,2

Some women develop a migraine every month anywhere from 2 days before to 2 days after the start of their period. Other women have migraines tied to their period and also at other times of the month. Migraine without aura is more common when estrogen levels drop at the start of a menstrual period (menses) or when stopping birth control pills or hormone therapy.1,2

What causes menstrual migraine?

Being female is 1 of the greatest risks for developing migraine. In fact, 1 in 5 women have migraines compared to 1 in 16 men. Menstrual migraines tend to start in the early teen years and happen much less often after menopause, which seems to prove that estrogen levels in the body cause migraine.1

Doctors believe that changes in estrogen levels trigger a reaction to nerves in the brain. This reaction leads to physical and biochemical changes in the brain that cause migraine symptoms. The changes include:

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  • Cortical spreading depression
  • Stimulation of the trigeminal vascular system
  • Release of the brain chemical calcitonin-gene-related peptide (CGRP)
  • Increases in the brain chemical serotonin
  • Nerve sensitization

Diagnosing menstrual migraine

The first step in diagnosing menstrual migraine is to find out if you have migraines or a hormone-related headache. This requires a physical exam and a discussion of your symptoms. Your doctor will need to know these things:1,

  • How often you have head pain
  • Whether you have aura symptoms such as seeing halos, zigzag lines, numbness, or blind spots
  • If you have nausea, vomiting, or sensitivity to light or sound
  • Where the pain is felt and if it gets worse when you move
  • Exactly when these attacks happen, such as the day before your period starts or randomly throughout the month

When a woman has migraine attacks only during her period, she is diagnosed with pure menstrual migraine. It is more common for women to have migraine attacks throughout the month plus during their period. This is diagnosed as menstrual-related migraine.

Treating menstrual migraine

Doctors generally recommend 3 different ways to treat menstrual migraine. It may take some trial and error to find which combination of treatments work for you. The options include:3

  • Long-term prevention: A medicine taken every day of the month. Examples include hormone therapies.
  • Mini-prevention: A medicine taken before and during the menstrual period. Examples include NSAIDs, hormone therapy, triptans, and magnesium.
  • Acute: A medicine taken at the beginning of an attack to try and reduce the severity and symptoms. Examples include fast-acting triptans taken with a pain reliever.

Keeping a migraine diary that records the details of your attacks and menstrual cycle will help you and your doctor spot trends in the timing and severity of your symptoms. This information will help you find the treatment options that work best for you.

Menstrual migraine and risk of stroke

There is some question whether using hormone-based birth control, such as pills, patches, and vaginal ring, is safe in women with migraine. Current medical thinking says that:1

  • Women who have migraine without aura can safely use birth control that contains estrogen.
  • Women who have migraine with aura generally should not use birth control that contains estrogen.
  • Having endometriosis in addition to migraine may change this recommendation.
  • Women with migraine have a slightly higher risk of stroke and birth control containing estrogen may increase that risk.

Other things to know about menstrual migraine

Menstrual migraine can be better or worse at certain times in a woman’s life, including:1,

  • Pregnancy seems to reduce the number of migraines a woman has, but the migraines she does have are worse during the first trimester and get better by the second trimester
  • After delivery, migraines may get worse, with severity and length of migraine increasing
  • Women who are breastfeeding should not take some migraine drugs, such as ergots and codeine
  • Migraine attacks may get worse during perimenopause, but many women report significantly fewer migraine attacks after menopause