OVERVIEW

What is estrogen-related migraine?

Estrogen-related migraine is a subtype of migraine, referring to headaches triggered by a drop in estrogen levels after prolonged elevation due to various factors.

Estrogen decline is one of the key factors contributing to migraines in women.

Who is prone to estrogen-related migraine?

It commonly occurs in the following women:

• Around the start of their menstrual cycle;
• Shortly after childbirth;
• Approaching menopause;
• Discontinuing regular estrogen-containing medications or experiencing reduced absorption.

How common is estrogen-related migraine?

The peak prevalence of migraines in women occurs in their early 40s, with some studies suggesting up to 41% of women may experience migraine attacks before age 50.

Up to 70% of female migraine sufferers report menstrual-related triggers. Pure menstrual migraine (affecting 7%–21% of female migraineurs) is less common than menstrually related migraine (affecting 35%–56%).

What are the types of estrogen-related migraine?

• Menstrual migraine: Closely timed with menstruation, typically occurring 2 days before to 3 days after the start of the period;

• Perimenopausal migraine: Begins 4–7 years before menopause and improves after menopause;

• Exogenous hormone-induced migraine: Occurs or worsens within 3 months of starting estrogen-containing medications and resolves within 3 months of discontinuation;

• Exogenous estrogen withdrawal migraine: Develops within 5 days of stopping ≥3 weeks of daily estrogen therapy and resolves within 3 days.

SYMPTOMS

What are the typical manifestations of estrogen-related migraines?

The symptoms of this condition are similar to those of non-estrogen-related migraines. The typical presentation consists of four phases:

Prodromal phase: Refers to emotional or autonomic symptoms occurring 24–48 hours before the attack, such as increased yawning, depression, irritability, euphoria, etc.

Aura phase: Gradually developing aura symptoms lasting no more than 1 hour, mainly manifested in the following aspects:

• Visual (e.g., bright lines or shapes in the visual field, vision loss, etc.)
• Auditory (e.g., tinnitus, noise, or hearing loss)
• Somatosensory (e.g., burning sensation, pain, or numbness)

Relatively speaking, estrogen-related migraines are less likely to be accompanied by the above aura symptoms.

Headache phase: Often unilateral, throbbing in sync with the pulse, possibly accompanied by nausea, vomiting, phonophobia, or photophobia.

Post-headache phase: The headache subsides, but sudden head movements may trigger brief pain in the previously affected area.

CAUSES

What is the etiology of estrogen-related migraines?

The primary cause of this condition is a sustained high level of estrogen in the body that subsequently declines due to various factors.

As mentioned earlier, these factors include the onset of the menstrual cycle, recent childbirth, approaching menopause, discontinuation of previously regular estrogen-containing medications, or reduced absorption capacity.

DIAGNOSIS

What tests are needed to diagnose estrogen-related migraine?

Typically, blood pressure, body temperature, inflammatory tenderness in the head and paranasal sinus areas, and mental status are checked.

Additionally, a head CT or MRI may be required to rule out headaches caused by organic conditions such as hypertension, sinusitis, or intracranial lesions, as well as other functional headaches (e.g., tension-type headaches). A diagnosis is made based on the combined assessment of these causes and symptoms.

Which conditions are easily confused with estrogen-related migraine?

This condition is often mistaken for other types of headaches, such as tension-type headaches, trigeminal autonomic cephalalgias, or headaches caused by head/neck trauma, cerebrovascular diseases, or intracranial lesions. Differentiation can be achieved through medical history, clinical presentation, and relevant tests.

TREATMENT

Which department should I visit for estrogen-related migraines?

Neurology.

How is estrogen-related migraine treated?

1. During acute episodes, symptomatic pain relief is typically prioritized.

Common medications include:

• Nonsteroidal anti-inflammatory drugs (NSAIDs): Diclofenac sodium, ibuprofen, etc., sometimes combined with triptans;
• Triptans: Sumatriptan, frovatriptan, naratriptan, etc.;
• Antiemetics: Injectable metoclopramide, chlorpromazine, etc.;
• Ergotamines: Dihydroergotamine, etc., which can be combined with antiemetics.

2. If acute treatment is insufficient or unsatisfactory, preventive therapy is needed.

For women requiring contraception or estrogen-based medications for other reasons, estrogen-based preventive therapy is recommended.

The initial approach involves extended-cycle combined estrogen-progestin contraceptive pills or 10 μg ethinyl estradiol preparations. The second option is estrogen supplementation targeting menstrual cycle fluctuations.

If estrogen therapy is contraindicated or the patient opts to avoid estrogen, non-hormonal treatments like long-acting triptans (taken twice daily, starting 2 days before expected menstruation and continuing for 5 days) may be considered.

Patients with estrogen-related migraines may also experience emotional distress. While focusing on symptom relief, it’s important to address emotional well-being through lifestyle changes (e.g., meditation, exercise) or counseling. Support from family and friends can also be highly beneficial.

What precautions should be taken during drug treatment for estrogen-related migraines?

• Acute-phase medications may cause rebound headaches. Avoid overuse—e.g., limit triptans to <10 days/month and NSAIDs to <15 days/month.

• Triptans are contraindicated in patients with hemiplegic migraine, acute cerebral infarction, coronary artery disease, angina, uncontrolled hypertension, or pregnancy. NSAIDs should be used cautiously in those with peptic ulcers, heart/kidney dysfunction.

Is follow-up needed after treatment for estrogen-related migraines?

Yes. Regular follow-ups to monitor symptom improvement are advised per medical guidance.

Can estrogen-related migraines be completely cured?

Postmenopausal women who no longer use estrogen-containing medications will experience stable estrogen levels, leading to significant improvement or resolution of the condition.

DIET & LIFESTYLE

What should patients with estrogen-related migraines pay attention to in daily life?

Patients should ensure adequate sleep (to avoid poor mental recovery after waking), maintain regular meals (avoid skipping meals), engage in moderate exercise, avoid smoking and excessive alcohol consumption as much as possible, and maintain an optimistic and positive attitude.

Can patients with estrogen-related migraines have normal fertility?

Yes.

Is estrogen-related migraine hereditary?

It is possible. Studies suggest that certain genes are associated with the occurrence of this condition.

PREVENTION

Can Estrogen-Related Migraines Be Prevented?

Yes, prevention is possible through lifestyle adjustments and medication as mentioned earlier:

• Lifestyle Adjustments: Ensure around 7 hours of quality sleep daily, avoid staying up late, maintain a regular diet, and exercise moderately.

• Medication Prevention: Doctors will make choices based on factors like coexisting conditions, drug side effects, and patient acceptance. The principle is to avoid sudden drops in estrogen levels.

• Menstrual Migraine: For those needing contraception, estrogen therapy, or if lifestyle changes fail, options include extending continuous estrogen-progestin contraceptives or estrogen supplementation (via patches/gels) around menstruation. For patients who cannot use estrogen-containing drugs, triptans can be taken starting 2 days before menstruation for 5 days.

• Exogenous Hormone-Induced Migraine: For oral estrogen therapy, continuous regimens are recommended. Alternatives include transdermal estrogen (patches/gels) or vaginal rings to minimize estrogen fluctuations.

• Exogenous Estrogen Withdrawal Migraine: Adjust oral estrogen intake to bedtime, extend continuous contraceptive use, or reduce dosage to the minimum.