NEW YORK, Sept 23: Migraine attacks are not just ordinary headaches; they can inflict intense pain and debilitating sickness that last for hours or even days. For millions of women, these attacks are a recurring ordeal rather than a rare occurrence. Research indicates that women suffer from migraines three times as often as men, with episodes that are typically more prolonged and severe.

“It’s far more common than most people realize,” says Anne MacGregor, a specialist in headache and women’s health. Despite the availability of various treatment options, migraines remain the leading cause of disability-adjusted life years (DALYs) among women aged 15 to 49, highlighting the significant burden these headaches impose.

The prevalence of migraines among women can largely be attributed to hormonal fluctuations. During early childhood, boys are slightly more prone to migraines than girls, but this balance shifts dramatically at puberty. The onset of menstruation coincides with significant hormonal changes, which often marks the time when girls first experience migraines. From puberty onwards, the disparity becomes increasingly pronounced, peaking in the mid-thirties and persisting into later life. “It’s chaotic at the two ends of a woman’s reproductive years,” MacGregor explains.

Many women report experiencing migraines in conjunction with their menstrual cycle, particularly due to a sharp decline in estradiol—a potent form of estrogen—just before menstruation. This late luteal phase sees estradiol levels plummet, leading to increased migraine susceptibility. Women who are more vulnerable to migraines tend to experience a quicker decline in estradiol during this period. While estrogen levels also drop around ovulation, the decrease is not as rapid, which may explain why migraines are less common then.

As women transition into perimenopause, a period marked by erratic hormonal changes, many who previously did not experience menstrual migraines begin to suffer from them. While some women may find relief post-menopause, this pattern is not universal. Richard Lipton, a neurologist and epidemiologist at Albert Einstein College of Medicine, emphasizes that the variability of experiences highlights the complex relationship between hormones and migraines.

Although estrogen’s role in migraines is well-documented, the precise mechanisms remain elusive. Lipton notes that migraines are characterized by a “sensitive brain,” which is particularly vulnerable to external factors, including hormonal changes that can trigger attacks. However, estrogen does not act in isolation. Its fluctuations also influence other hormones, such as serotonin, which typically helps mitigate pain sensitivity. When estrogen levels drop, serotonin levels decrease as well, further increasing the likelihood of migraine episodes.

Migraine triggers often act in tandem. Factors such as lack of sleep, irregular meals, dehydration, and stress can combine with hormonal fluctuations to precipitate an attack. Additionally, estrogen’s interaction with calcitonin gene-related peptide (CGRP), a chemical that facilitates communication between nerve cells, complicates the picture. CGRP is known to dilate blood vessels and increase blood flow, both of which are implicated in the onset and intensity of migraines. Research indicates that women have higher levels of CGRP than men, and estrogen fluctuations can influence CGRP activity in the brain’s pain pathways.

Recent studies are exploring the potential role of progesterone, another sex hormone, in migraine susceptibility. Researchers at the University of Virginia found that activating progesterone receptors in the brain may increase pain sensitivity. In experiments with mice treated with nitroglycerin—used to simulate migraines—administering progesterone made the subjects more sensitive to pain, demonstrating avoidance behaviors in response to light and pinprick sensations. Suchitra Joshi, the lead author of the study, asserts that this previously overlooked role of progesterone could lead to new treatment options for migraine sufferers.

New research initiatives are also mapping genetic components associated with migraines in women and driving a broader understanding of sex-specific factors in migraine pathology. This evolving landscape is challenging outdated stereotypes about “hysterical” or “sensitive” women, which have historically colored perceptions of migraines.

Despite the increased likelihood of women receiving a migraine diagnosis, gender disparities in treatment persist. Women are often less likely to be prescribed effective medication than their male counterparts. Lipton notes that characterizing migraines as a “women’s disease” can lead to dismissive attitudes toward their severity. “Men diagnosed with migraine are more likely than women with migraine to be treated,” he adds.

As research into migraines continues to evolve, understanding the distinct challenges women face in managing these debilitating headaches is critical. While hormonal influences are a significant factor, the broader context of social attitudes and medical responses to migraines must also be addressed. The goal is to ensure that women receive appropriate care and treatment that acknowledges the unique aspects of their experiences with migraines.