Hormonal Migraines: Understanding the Cycle Connection

Migraine affects women three times more than men. This isn't a coincidence — it's hormones. Specifically, it's the fluctuation of estrogen throughout the menstrual cycle that makes women disproportionately vulnerable to migraine attacks.

Between 60% and 75% of women with migraines report a connection to their menstrual cycle. Yet despite this overwhelming statistic, hormonal migraines remain underdiagnosed, undertreated, and almost completely ignored by most migraine tracking apps. Let's change that.

What Is a Menstrual Migraine?

The International Classification of Headache Disorders (ICHD-3) defines two types of menstrually related migraine:

• Pure menstrual migraine (PMM): Attacks occur exclusively on Day -2 to Day +3 of menstruation (two days before to three days after the first day of your period), with no attacks at other times. This is relatively rare, affecting about 7-10% of women with migraine.
• Menstrually related migraine (MRM): Attacks reliably occur during the perimenstrual window (Day -2 to Day +3) but can also occur at other times in the cycle. This is much more common, affecting about 50-60% of women with migraine.

The key diagnostic criterion is that these attacks must occur in at least 2 out of 3 consecutive cycles. A single period-migraine doesn't qualify — you need the pattern.

The Estrogen Drop Theory

The dominant theory, supported by decades of research, is that it's the drop in estrogen that triggers menstrual migraines — not the absolute level. Estrogen naturally peaks during the late follicular phase (around ovulation) and then drops sharply in the late luteal phase (a few days before your period). This rapid decline is the trigger.

It's not low estrogen that causes migraines — it's the withdrawal. The brain has adapted to high estrogen levels, and when they drop rapidly, migraine-related pathways are activated.

This explains why menstrual migraines cluster around the start of menstruation (maximum estrogen drop), and why some women experience migraines at mid-cycle too — estrogen also dips briefly after the ovulatory surge.

It also explains several clinical observations:

• Pregnancy often relieves migraines: Estrogen is consistently high during pregnancy, with no withdrawal episodes
• Menopause often worsens migraines initially: The perimenopausal period is characterized by erratic hormone fluctuations, leading to more attacks. Post-menopause, when hormones stabilize at low levels, migraines often improve
• Oral contraceptives have variable effects: Some pills worsen migraines (the placebo week causes an artificial estrogen withdrawal), while continuous-dose pills that skip the placebo week may help

Beyond Estrogen: The Full Picture

While estrogen gets most of the attention, other hormonal players are involved:

• Progesterone: Falls alongside estrogen in the late luteal phase. Some research suggests progesterone withdrawal may independently contribute to migraine susceptibility
• Prostaglandins: Released during menstruation to help shed the uterine lining. Prostaglandins are also inflammatory mediators that can sensitize pain pathways, potentially amplifying migraine pain during periods
• Serotonin: Estrogen modulates serotonin receptor expression. When estrogen drops, serotonin activity changes — and serotonin is the primary neurotransmitter targeted by triptans (the most effective acute migraine treatment)
• CGRP: Calcitonin gene-related peptide, the target of newer migraine medications (gepants, CGRP monoclonal antibodies), is influenced by estrogen levels. Estrogen withdrawal increases CGRP release, promoting vasodilation and neurogenic inflammation

How to Track Hormonal Migraines

Identifying hormonal migraines requires tracking two things simultaneously: your attacks and your menstrual cycle. Here's the method:

1. Log Your Cycle Accurately

Track the first day of each period, the length of your cycle, and if possible, symptoms that indicate ovulation (cervical mucus changes, mittelschmerz, or ovulation test results). This gives you the four phases: menstrual, follicular, ovulatory, and luteal.

2. Map Attacks to Cycle Phases

For each migraine attack, note which cycle phase you were in. After 3+ cycles, look at the distribution. If a disproportionate number of attacks cluster in the late luteal or menstrual phases, you likely have a hormonal component.

3. Compare Intensity and Duration

Menstrual migraines are often more severe, last longer (up to 72 hours vs the typical 4-24 hours), are more resistant to medication, and have higher recurrence rates than non-menstrual attacks. Track not just frequency, but also severity and duration by cycle phase.

4. Track for At Least 3 Cycles

The ICHD-3 requires a pattern across at least 2 out of 3 consecutive cycles for diagnosis. Individual months can vary due to stress, travel, or other factors. Three months gives you a reliable picture.

Treatment Approaches for Hormonal Migraines

Once you've confirmed a hormonal pattern, several treatment strategies become available. Always discuss these with your neurologist or gynecologist:

• Mini-prevention: Taking a triptan or NSAID (like naproxen) during the high-risk perimenstrual window, starting 2 days before expected menstruation and continuing for 5-7 days. This is the most common approach.
• Continuous hormonal contraception: Using combined oral contraceptives without the placebo week eliminates the artificial estrogen withdrawal. Must be prescribed by a doctor — not suitable for all migraine patients (especially those with aura).
• Estrogen supplementation: Applying estrogen gel or patches during the late luteal phase to smooth out the natural estrogen drop. Shows promise in research but requires medical supervision.
• CGRP-targeting medications: Newer treatments like gepants (ubrogepant, rimegepant) and CGRP monoclonal antibodies (erenumab, fremanezumab) show particular effectiveness for menstrual migraines.
• Magnesium supplementation: Taking 400mg magnesium glycinate daily, starting at Day 15 of the cycle through the end of menstruation, has shown modest benefits in some studies.

What Your Doctor Needs to See

When you visit your neurologist about suspected hormonal migraines, bring data. A printout showing your attack pattern overlaid on your cycle phases is infinitely more useful than "I think my migraines are related to my period."

Your doctor specifically needs: at least 3 months of attack dates with severity ratings, corresponding menstrual cycle dates and phase information, medication usage and effectiveness by cycle phase, and ideally a MIDAS or HIT-6 disability score. With this data, your doctor can make a confident diagnosis and prescribe targeted treatment.

The Bigger Picture

The fact that 60-75% of women with migraines have a hormonal component — yet most migraine apps don't even include cycle tracking — is a significant gap in healthcare technology. Women shouldn't need separate apps for migraine tracking and cycle tracking. The two are biologically intertwined, and your tools should reflect that.

Understanding your hormonal migraine pattern doesn't just help with treatment. It gives you predictive power. If you know that the late luteal phase is your highest risk period, you can proactively optimize sleep, reduce stress, stay hydrated, and have rescue medication ready. You shift from reactive to proactive — and that changes the relationship with your migraines entirely.