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Migraine in Women

Brandes, Jan Lewis MS, MD, FAAN

CONTINUUM: Lifelong Learning in Neurology: August 2012 - Volume 18 - Issue 4, Headache - p 835–852
doi: 10.1212/01.CON.0000418646.70149.71
Review Articles

Purpose of Review: This article discusses hormonal milestones and the influence that hormonal fluctuations make in the frequency and severity of migraine in women and includes information on acute, short-term, and preventive strategies for hormonally influenced migraine and the situations in which hormonal therapies may be offered.

Recent Findings: Genomic patterns in adolescent girls differentiate between menstrually related migraine and non–menstrually related migraine. The age at initiation of estrogen replacement therapy appears to be significant with respect to stroke. No increase in stroke occurred in women on low-dose (50 µg or less) transdermal estrogen replacement compared to women not using estrogen replacement. Childhood maltreatment is more common in women with migraine and depression than in women with migraine alone.

Summary: Management of hormonally influenced migraine involves a clear identification of the relationship between migraine and hormone change. A thorough history and detailed diary are critical in identifying this relationship and in predicting response or following response to hormonal therapies. The evolution of migraine in an individual may be strongly driven by hormonal shifts. Although limited, clinical evidence suggests that oral contraceptive use in young women with episodic migraine may transform their pattern into chronic migraine. Thus, particular attention to changes in migraine patterns following either endogenous or exogenous hormonal changes is crucial. Providing reassurance and education that migraine is a biological disorder and providing an understanding of the role of estrogen in the frequency and severity of migraine can guide treatment choices. Pharmacologic treatments include acute therapy, with short-term and standard prevention offered where appropriate. Hormonal therapies are not first-line therapies but may be important choices for a woman with migraine whose estrogen fluctuation is continually exacerbating migraine attacks. Given the many hormonal stages during the life of a woman with migraine, therapies may vary according to hormonal stage and status. Overall wellness should also be emphasized; regular exercise, balanced diet, smoking cessation, weight control, and sleep hygiene are important in the management of migraine.

Address correspondence to Dr Jan Brandes, Nashville Neuroscience Group, 300 20th Avenue North, 106, Nashville, TN 37203,

Relationship Disclosure: Dr Brandes serves as a consultant and/or speaker for Allergan, Inc., Astellas Pharma US, Inc., GlaxoSmithKline, MAP Pharmaceuticals, Inc., Merck & Co., Inc., Nautilus Pharma, NuPathe, Inc., and Zogenix, Inc. Dr Brandes receives research grants and support from Allergan, Inc., Astellas Pharma US, Inc., AstraZeneca, Boston Scientific Corporation, Eli Lilly and Company, GlaxoSmithKline, MAP Pharmaceuticals, Inc., Merck & Co., Inc., Novartis, NuPathe, Inc., and Zogenix, Inc.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Brandes discusses the unlabeled use of medications for hormonal management and nonhormonal management of migraine in women, none of which are specifically US Food and Drug Administration approved for migraine.

© 2012 American Academy of Neurology
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