Why are migraine headaches so common during menstruation?

  • A new study has found that migraine attacks experienced by cisgender women during menstruation may be the result of an increase in the peptide CGRP, which has been linked to migraines.
  • This increase corresponded in the study to a reduction in estrogen that occurs during menstruation.

Study finds no increase in CGRP among contraception users or menopause participants, despite potential migraine symptoms.

For decades, experts have known that a decline in estrogen levels is linked to the start of menstruation-related migraine attacks. However, the mechanics behind this connection have remained unclear. Study reveals hormonal fluctuations impact migraine peptide levels, with CGRP increased during menstruation dropping and affecting migraine symptoms.

Close-up image of a woman holding her head in pain, symbolizing a migraine headache.

A pilot study suggests CGRP release may trigger menstrual migraine due to reduced estrogen levels. It may also explain why menstrual attacks occur during menstruation, and why they decline in frequency after menopause. The study appears in Neurology.

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 CGRP and menstrual stages

The study was a cross-sectional, matched-cohort study conducted at the Headache Center, Department of Neurology, Charité Universitätsmedizin Berlin in Germany. The study focuses on 180 cisgender women with three or more migraines. The researchers divided the participants evenly divided into three groups:

1.   women with regular menstrual cycles

2.   women taking contraceptives

3.   women who had gone through their menopausal stage.

Age-matched women who did not get migraines served as a control group.

To assess levels of CGRP, the researchers analyzed blood and tear samples taken from study participants. Samples were collected from menstrual cycle participants, women on birth control, and during hormone-free and intake intervals. Samples were taken just once from women post-menopause, on a random day.

Migraine-prone women had higher levels of CGRP (5.95 pg/ml) during menstruation compared to those without migraines (4.61 pg/ml). During ovulation, hormone levels peak, CGRP levels decrease, indicating migraine cessation after menstruation.

Migraine-prone women have 1.20 nanograms of CGRP, and women have 0.4 ng/ml. Contraceptives and post-menopause women did not show the same increase. This suggests that attacks experienced by the women in these groups are likely not triggered by CGRP.

Tear sampling

Tear sampling, considered experimental, supports further use and exploration in measuring CGRP, as it offers a non-invasive method.

In addition, Dr. Raffaelli explained to MNT, “[d]ue to the anatomical proximity to the trigeminal nerve, CGRP in the tear fluid is more likely to reflect the trigeminovascular release of CGRP, while CGRP in blood could also come from other sources.”

Hormones and CGRP

The study explores the role of female hormones in exacerbation, according to Neurologist Dr. Shazia Afridi. Animal studies suggest estrogen influences CGRP expression in the trigeminovascular system, but few human studies. Dr. Afridi links hormone levels to CGRP expression in nerve cells. This supports previous research, according to Dr. Regina Krel, a specialist at Hackensack University Medical Center.

“I was not surprised to see the results of this study,” she told Medical News Today. Attacks are triggered by estrogen drops before menstruation, with higher CGRP levels in migraine patients. This study allows us to have an explanation of why that drop in estrogen triggers headaches.”

Migraine and contraception

Contraception may impact attacks, but outcomes are complex, according to Dr. Raffaelli and Afridi. Different types of contraception behave differently in relation to migraine, said Dr. Afridi. “There is some evidence that desogestrel can improve migraine in some cases,” she added. Desogestrel is the active ingredient in the progestogen-only contraceptive pill, also known as the “mini-pill.”

Oral contraceptives improve migraine symptoms in one-third of patients. Dr. Raffaelli found that oral contraceptives in a 21-7 cycle often worsen migraines. Long-cycle oral contraceptives appear to be associated with improvements. Estrogen-containing preparations and migraine with aura increase stroke risk, depending on estrogen dosage.

Spot prophylactic treatment may be beneficial for female patients with menstrually-related or pure migraines. This involves taking migraine-specific medications just before menstrual onset and continuing throughout the cycle to prevent headaches.

Dr. Krel suggests using approved CGRP blocking medications to prevent CGRP levels from rising as estrogen drops, or continuous estrogen birth control for patients without contraindications. This approach may prevent the drop in estrogen during this time.n turn also prevents the rise in CGRP levels.”

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