Understanding migraines: Triggers, prevention, treatment

  • Julie Feinland, CNM © Jim Gipe 2016

For the Gazette
Monday, August 07, 2017

Anyone who has ever experienced a migraine headache knows how painful and debilitating it can be. About one in six women in the United States are affected by this disorder compared to one in 17 men. Almost a quarter of women in their 30s are affected.

Migraine headaches are distinguished from the more common tension-type headache by the location and severity of the pain — migraines tend to be one-sided and moderately or severely painful — as well as other characteristics such as pulsating pain, nausea and vomiting. In addition, migraines are often made worse by sound, light, and routine physical activity such as walking.

About 25 percent of migraine sufferers also experience additional neurologic symptoms called auras, perceptual problems which most often involve the sense of sight, such as experiencing a strange light, but also can affect other senses and motor functions.

Although a genetic basis for migraines has not yet been established, they do run in families, with estimates ranging from 50 to 90 percent of sufferers reporting that other family members also experience them.

The list of possible migraine triggers is long and includes stress, hormonal fluctuations, fasting, weather changes, nitrates, wine and sleep disturbances. As this space is dedicated to discussion of women’s health, migraines related to women’s cyclic or ongoing hormonal changes are primarily what I’ve focused on.

Menstrual migraines

Menstrual migraines occur between two days before through three days after a woman’s period starts with at least two-thirds of the cycles affected by migraines. They are caused by the decrease in estrogen during that interval. Up to 70 percent of women who experience migraines report menstruation as a trigger (although 20 percent or less report that it is the only trigger).

Menstrual migraines tend to last longer, be more painful, and be less responsive to treatment than non-menstrual migraines.

Hormonal contraception

Some women who experience migraines have reported an increase in the number and severity of their headaches when taking oral contraceptives containing estrogen, others say the number of headaches decreases and some experience no change at all. Migraines usually occur during the hormone-free week of the oral contraceptive cycle and can often be improved by shortening the duration of the hormone-free period or changing to extended-cycle oral contraceptives

Because migraine sufferers who take oral contraceptives are at a higher risk for brain blood clots, the World Health Organization and the American College of Obstetricians and Gynecologists recommend that women 35 years or older, those who develop migraines while taking oral contraceptives and those who have migraines with aura avoid using contraceptive methods containing estrogen.

During and after pregnancy

About two out of three migraine sufferers experience improvement during pregnancy while one in 20 have worse migraines. The headaches usually return postpartum when estrogen levels fall, although breastfeeding stabilizes estrogen levels and appears to decrease the incidence of migraines. In one study of postpartum women with a history of migraine headaches, less than half of breastfeeding mothers had a migraine during the first postpartum month while all women who formula-fed reported a migraine in that time period.


The perimenopausal period occurs toward the end of the reproductive years. Many women experience menstrual changes as well as other symptoms related to hormonal fluctuations such as hot flashes and sleep disturbances. Migraine sufferers usually experience an increased number of migraines during this time due to uneven estrogen levels.

The good news is most women experience significantly fewer migraines once they have entered menopause. It’s unclear if estrogen replacement therapy affects the frequency or severity, so to minimize estrogen level fluctuations and migraines, continuous rather than cyclic therapy is recommended, as is transdermal or transvaginal (rather than oral) estrogen.


Lifestyle changes aimed at preventing migraines should target decreasing stress, eating at regular times throughout the day, avoiding triggers such as nitrates and wine, and getting enough sleep. Acupuncture has been shown to help prevent migraines in multiple studies, and some supplements, including magnesium, riboflavin and coenzyme Q10 also have proven to be effective. Other possible preventive treatments include chiropractic, massage, yoga, meditation and biofeedback.

Medical approaches to prevention suggest starting or changing a hormonal therapy regimen to reduce estrogen level changes. Taking a triptan medication (e.g. Imitrex®, Zomig®, Maxalt®) two days before a period starts and continuing for a week is effective in preventing menstrual migraines if you have regular menstrual cycles.


If preventive options are not successful, hormone-related migraines may be treated with triptans similarly to migraines with other causes. Non-steroidal anti-inflammatory (NSAID) medications either alone or with a triptan also can be helpful. Neither of these medications can be taken during pregnancy. Tylenol taken with caffeine can improve symptoms for some women. If it does not, the woman’s pregnancy care provider may prescribe a different medication. Triptans and NSAIDs are safe when breastfeeding

Acupuncture also has been shown to be an effective treatment for migraine headaches. Other complementary approaches include homeopathy, herbal remedies, massage and chiropractic.

Julie Feinland is a certified nurse midwife at Cooley Dickinson Women’s Health and at the Cooley Dickinson Childbirth Center in Northampton. She is also a certified acupuncturist through the Institute of Taoist Education and Acupuncture.

Women’s Health is written by health care professionals affiliated with Cooley Dickinson Hospital in Northampton. It appears here monthly