Headache, especially migraine is seen more frequently in women as compared to men. Besides the usual triggers like fasting, exposure to sunlight, lack of sufficient sleep, stress and menstrual cycles are important triggers in some women with migraine. This is attributed to decreased estrogen just before Menstrual cycles.
Menstrual Migraine and Estrogen Supplementation
When we spoke to Dr Aakash Agrawal, Consultant Neurologist, Manipal Hospital, Bhubaneswar, he said in cases of ‘menstrual migraine’ that are refractory to usual medicines, Low amounts of estrogens are given during these episodes of ‘menstrual migraine’ in refractory cases, which do not respond to usual medicines given to treat an episode of migraine. This approach helps address the dip in estrogen levels, which often triggers these headaches. However, women taking cyclic oral contraceptive pills for 21 days may experience estrogen withdrawal headaches during the 7-day ‘off’ phase due to a similar dip in estrogen levels.
The Double-Edged Sword: Estrogen and Migraine
The female hormone, given in the form of a compound called ethinyl estradiol, is a double-edged sword. Given at high doses, it can be the reason for strokes in females who have a type of migraine called a ‘migraine with aura’.
In this condition, the patient’s usual pattern of migraine headache is preceded by transient visual symptoms like scintillating lights or abnormal sensory symptoms in one side of the body or rarely paralysis and difficulty speaking. However, these are short-lasting and immediately precede the onset of a headache. The chances of having a stroke increase in these patients if they take estrogen, and this increases manifold in smokers or those with a family history of stroke.
Risk Reduction Strategies for Migraine
The risk is usually minimal at Modern doses of ethinyl estradiol prescribed nowadays or progestin-only pills, the other female hormone which seems innocuous in terms of stroke risk. Patients who have ‘migraine with aura’, should inform their gynaecologist/obstetrician about their condition as changes in hormonal pills can be made accordingly. Alternatively, other methods of contraception like Copper-T or progestin-only pills can be explored in these patients.
Hormonal Therapy in Postmenopausal Women
Post-menopausal hormonal therapy differs significantly from contraception. The amount of estrogen given is substantially lower and does not pose a risk of stroke in patients with ‘migraine with aura’ or smokers. Therefore, it can be safely taken in these cases.
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