Studies confirm that tension-type headache and migraine are more common in women while cluster headache, a rare form of headache, is more common in men. Many headache sufferers ‘suffer in silence’, not seeking the attention they need because of the stigma of headache, the perception that ‘headaches are all in the mind’. Medical research and initiatives such as the recent World Health Organisation declaration of headache as a disability is changing this perception. There is a wide range of precipitating factors (see Management of headache) that can trigger headaches and include dehydration, sport, blows to the head, inadequate workstations, stress and diet. Headaches can also be related to depression, marital conflict and substance abuse.
Headaches are more common in women than men, this difference being most obvious during the reproductive years. Female sex hormones are an important factor but not the only one. A London study showed that women are more prone to non-migraine headaches around the time of their period even if they are migraine sufferers. Headaches can occur during the pre-menstrual period, the menopause and when commencing oral contraceptives. Other than, at these times, hormonal changes have little effect on non-migraine headaches.
In childhood, the ratio of female to male migraine sufferers is about 1 to 1. During the reproductive years, that changes to about 3 female to 1 male. It is thought that more women suffer migraine because of hormonal factors. 15 per cent of women report their first migraine during the same year as the onset of their menstrual period. More than 50 per cent of women report menstruation as a migraine trigger. Opinions vary about the cause of this link but most experts agree that it is mainly a fall in the level of oestrogen that triggers the onset of migraine. Keeping your Headache Diary will assist your doctor to understand the effect of your cycle and to decide on the best treatment options.
Migraines associated with pre-menstrual syndrome (PMS), a common condition in which women develop tiredness, irritability, breast tenderness and gain in weight from fluid retention in the few days before menstruation, may improve with over-the-counter medications such as evening primrose oil, vitamin B6, or magnesium supplements. Seek advice from your doctor before taking high doses of vitamin B6 as it can have toxic side effects. If these do not help, your doctor may prescribe non-hormonal treatments such as naproxen or methysergide or hormonal treatments such as the combined contraceptive pill, oestrogen patches, or injections that ‘switch off’ the normal menstrual cycle avoiding the fall in oestrogen.
In the same way that female hormones can affect migraine, so can hormonal contraception. For some, migraine can occur for the first time when taking oral contraception, for some it has no effect on their migraine, for some it can make the migraine worse and for others it can bring an improvement. A few patients notice an improvement in their migraine when they start taking one form of the pill but the frequency and intensity of headaches increases for most patients on high dosage pills. This may be explained by the fact that oral contraceptives contain different combinations of synthetic oestrogens and progesterones. Some patients notice additional minor vascular headaches.
A very small group of women with migraine, those who have migraine with aura, who smoke, and who are taking combined oral contraception, have an increased risk of stroke. The risk of stroke in others taking the combined pill is extremely small unless other risk factors are present such as smoking, uncontrolled hypertension, diabetes or a family history of stroke.
Migraine in pregnancy can be a concern, especially if it occurs for the first time. Migraine does not put pregnancy at risk. Migraine can change during pregnancy. Studies suggest that 60-70% of migraine sufferers experience an improvement in their migraine during pregnancy, particularly during the second and third trimesters. This has been suggested as being the result of more stable levels of oestrogen during pregnancy. 5-30% stay unchanged during pregnancy and a small percentage get worse or observe a change such as the onset of aura. The same woman may have different patterns during different pregnancies. For those who do still suffer, manufacturers do not generally recommend the use of any drug during pregnancy. It is important that the doctor is consulted when a pregnancy is planned so that migraine management during pregnancy can be planned.
During the first week after the birth, 3-40% of women suffer from headaches, migraine frequently restarts, migraine may start for the first time. However, other headaches may also occur and should be investigated- they could be related to epidural anaesthesia, post-partum depression, cerebro-venous thrombosis or stroke.
The menopause actually means the last menstrual period but is used for the hormonal changes both before and after the last period. During the years leading up to the last period and shortly after, the climacteric, many women find the migraine worsens and those not previously aware of the link with their periods develop regular monthly migraine. Many women choose to undergo Hormone Replacement Therapy. HRT replaces the natural oestrogens that the ovaries are unable to produce. In theory, HRT should be good for migraine as the levels of oestrogen remain fairly constant. But once again, the reality can be quite different. HRT can aggravate migraine and can lead to an improvement. There are many different types of HRT available and the effect on migraine can vary according to the type used. If one type does not suit you, it is well worth trying another. Much of the literature suggests the non-oral HRT is better for women with migraine. It is important that the dosage is correct as too little HRT can trigger migraine attacks and too much can cause side effects such as fluid retention and nausea and can trigger migraine and migraine aura. HRT can help but is not a miracle cure as it can’t affect the other migraine triggers.
Young women may develop behaviours that adversely affect headaches such as skipping meals, unbalanced eating patterns, irregular sleep patterns, too much caffeine (coffee, cola, chocolate) and may be affected by depression or abuse. Effective treatment of headache in women relies on effective communication between the patient and the doctor and on them working together on the Management of headache.
Elderly people can experience many types of headache including migraine, tension-type headache and chronic daily headache. For many, headaches improve as they get older. Migraines are less severe and less frequent. Occasionally headaches will develop or change and this should be investigated if they do not respond readily to treatment. Headaches that can affect elderly people include: side effects of medications (such as glyceryl trinitrate and blood pressure drugs), trigeminal neuralgia, temporal arteritis, depression (which can result from lack of sleep and poor nutrition), brain tumour, and strokes. As one grows older arteries develop a build up reducing blood flow. This is known as atherosclerosis and is linked to strokes and heart disease. Migraine can mimic symptoms, such as visual disturbances, of transient ischaemic attacks (TIAs, mini strokes). Those who develop migraine symptoms late in life or problems with vision should consult their doctor immediately. It is also important that elderly people who begin having chronic headaches or a different kind of headache consult a doctor rather than self-medicating. Elderly people are more prone to side effects from medications such as aspirin-containing medications and anti-inflammatories and have a reduced ability to process drugs as liver and kidney function slows down. Other medical conditions such as glaucoma, ulcers, diabetes can limit the choice of headache medication. There are effective treatments for headache in the elderly and the secret to this is working with your medical practitioner to manage headache.
Migraine and other headaches, 2000 ed, Professor James Lance
Understanding Migraine and other Headaches, 2002 ed, Dr Anne MacGregor
Headache, menstruation and oral contraceptives, Dr Astrid Eikermann, Germany, Headache World 2000
Headache and pregnancy, Dr Helene Massiou, France, Headache World 2000
Headache, the menopause and HRT, Dr Anne MacGregor, England, Headache World 2000
Prepared by Louise Alexander, PhC, Grad Dip Comm Mngt, Former National Director of the Brain Foundation. Reviewed by Professor James Lance, AO, CBE, MD, Hon DSc, FRCP, FRACP, FAA, Consulting Neurologist, and author, “Migraine and Other Headaches”