Doctor on Call: How and why does migraine differ in males vs females?
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Amelia, a 52-year-old cancer research scientist who lives and works in Bethesda, Maryland, writes…
Dear Doctor,
My husband is 10 years older than me. We both have migraine, but throughout our 26 year marriage migraine consistently has been more of a problem for me than it has been for him. This has become especially true over recent years.
When he hit his 50s, the frequency of his visual aura episodes increased, but his migraine headaches virtually ceased. For the past 2 or 3 years my menstrual cycle – always clock-like predictable in the past– has become increasingly irregular, and with this also have come not just the night sweats all my menopausal friends talk about, but also uncharacteristic (for me) difficulty sleeping, difficulty concentrating at work, an embarrassing tendency to forget people’s names and – most of all – a giant increase in my headache burden.
What is going on with me? Why is my husband aging gracefully and headache-free while I have become an insomniac beset by “brain fog” and more problems with headache than I have ever had?
— Distressed (and prematurely senile?)
in Bethesda
The Doctor’s Reply:
Dear Amelia,
The differences between men and women are oft mysterious, but in the case of migraine, the headache disorder that you and your husband share, there is a biologic explanation for your differences.
Depending in part upon the study and the country and culture of the population surveyed, the prevalence of migraine in females is roughly 3 to 4 times that reported for males. Does that mean migraine is genetically more common in females than it is in males? Unknown, but I doubt it. Prior to the onset of puberty migraine is actually more prevalent in males. The preponderance of migraine in females is most obvious between the ages of 15 and 45, and as females begin to exit the years of child-bearing potential the prevalence begins to even out again. While the possibility exists that some biologic variants of migraine may have a sex-linked genetic inheritance pattern, it seems more likely that the genetic predisposition for migraine is more or less equal between the two genders but more often clinically expressed in females…and especially so during the years of child-bearing potential.
Why? Well, migraine thrives on change, and this gender-related difference in the clinical expression of migraine has been attributed to the built-in changes in the levels of sex hormones that occur during the menstrual cycle. In females there are certain times when migraine tends to become more of a problem: menarche (the onset of puberty), menses, childbirth and the perimenopause. All are times of hormonal instability. In contrast, while nothing is ever “always” when it comes to migraine, migraine tends to become clinically quiescent during pregnancy (especially the last two trimesters) and also following menopause. Both are times of relative hormonal stability.
If your migraine burden is high, I encourage you to seek out a headache specialist for evaluation and treatment. In addition, you are describing symptoms characteristic of “menopausal syndrome” – night sweats, reduced cognitive function/”brain fog”, problems with sleep – that may first arise during the few years leading up to menopause. Are you taking hormone replacement therapy (HRT)? If not, this is something you definitely should discuss with your primary care provider or gynecologist. Supplemental estrogen (taken concomitantly with progesterone if you have a uterus) can make a huge and positive difference, and there is evidence that HRT is most effective when begun earlier rather than later relative to menopause (which is defined as the absence of menses for 12 consecutive months). Many of the concerns regarding HRT that resulted from the Women’s Health Initiative (egs, risk of breast cancer, risk of cardiovascular or stroke complications) appear to have been inappropriately exaggerated, and the benefits of HRT are becoming increasingly recognized. Low-dose estrogen supplementation via, say, a skin patch applied weekly can make a tremendous difference in your perimenopausal/menopausal symptoms and perhaps help reduce your headache burden as well.
Premenstrual dysthymic disorder (“PMS”), perimenopausal/menopausal symptoms and HRT generally represent major female health issues that have deserved more attention than they have received to date. We are learning now how important estrogen receptors are to brain function and how a deficiency of estrogen may affect that function adversely.
One wonders whether a similar circumstance involving males and testosterone might have received far more attention and active intervention far earlier.
Again, Amelia, I encourage you to put down this magazine and make appointments to see a headache specialist and either your PCP or gynecologist. Your brain will thank you for it.
