Many individuals diagnosed with menstrual or hormonal migraine experience significant headaches around Day 1 of their cycle, coinciding with a drop in oestrogen levels. This has led to the common belief that hormones are to blame. However, it might be time to re-evaluate this perspective. For instance, why do many women also experience similar headaches, though typically less severe, at mid-cycle when estrogen levels peak? This doesn’t quite add up.
What is Menstrual Migraine?
Menstrual Migraine can be divided into two types:
Pure Menstrual Migraine (PMM): This type occurs only around two days before or after Day 1 of the menstrual cycle and not at any other time during the cycle.
Menstrual-related Migraine (MRM): Similar to PMM, MRM occurs around two days on either side of Day 1 but also at other times in the cycle, often around mid-cycle, though not always confined to this time.
Those who experience MRM generally find their PMM to be more severe, longer-lasting, more resistant to medication, and often accompanied by more intense associated symptoms like nausea and vomiting, making it more disabling.
Is It All About Hormones (Oestrogen)?
This question becomes less complicated when considering that oestrogen, a systemic biochemical, affects both sides of the body. Yet, most menstrual migraines are characterised by one-sided headaches, with some even swapping sides between episodes or within the same episode. Hormones do not selectively affect one side of the body or switch sides.
Furthermore, research has shown that the hormonal profiles, including the degree and pattern of fluctuations, are no different between women with menstrual migraines and those without.
To quote summaries of the MM situation: “… the exact underlying pathophysiological mechanisms (cause) are still not completely understood.”1 (p 304) and “Although there is a great wealth of knowledge about the neurobiological processes underlying MM and its symptoms, the mechanism by which an attack starts during the menstrual cycle remains baffling, and the disease is still untreated.”2(p 2355) (The use of the word “disease” is debatable, but that’s another topic.)
Artificially manipulating hormones is not the answer.
This can be pretty disheartening, but here is what is known: research has shown that women with MM have a sensitised brainstem, which is widely accepted as the underlying issue in migraine conditions. This is why the ‘best practice’ in treating MM is with a ‘triptan,’ a migraine-specific medication that aborts migraines by desensitising the brainstem. However, this medication does not address the underlying cause or source of sensitisation.
Experience-Based Care
The approach described here is based on clinical experience rather than just following guidelines. While it might be assumed that MM is purely hormonal, evidence suggests that other factors, such as cervical or neck issues, could also be contributing, and addressing these factors can lead to resolution or significant improvement.
Research has demonstrated that the nerves in the upper neck relay information to the brainstem; if this information is abnormal, it can sensitise the brainstem. Furthermore, additional research has shown that treating the upper neck with non-manipulative techniques (i.e., non-cracking) can de-sensitise the brainstem, similar to triptan medication, but potentially provide long-term relief.
Conclusion
In conclusion, exploring other potential causes and treatment options is essential, especially if menstrual migraines are preceded or accompanied by neck symptoms. Moreover, if the headache is one-sided and can switch between episodes or within the same episode, musculoskeletal issues in the neck are the source.
Reference:
1. Vetvik KG, MacGregor EA. Menstrual migraine: a distinct disorder needing greater recognition. Lancet Neurol. Apr 2021;20(4):304-315.
2. Cupini LM, Corbelli I, Sarchelli P. Menstrual migraine: what it is and does it matter? Journal of Neurology. Jul 2021;268(7):2355-2363.
