Are migraine and hormonal changes connected?

Yes. Migraine is more common in women than men after puberty, and hormonal fluctuations — particularly the drop in oestrogen before menstruation — are a major trigger for many women. Menstrual migraine (attacks consistently occurring around menstruation) is a recognised subtype. Hormonal contraception and HRT can improve or worsen migraine depending on the type and the individual. Migraine with aura is associated with an increased risk of stroke, and combined oral contraceptives are generally avoided in women with migraine with aura.

Migraine: Symptoms, Triggers, and Treatment

Summary

Migraine is a complex neurological condition characterised by recurrent attacks of moderate to severe headache, typically with associated symptoms including nausea, and sensitivity to light and sound. It affects approximately 15% of the global population and is one of the leading causes of years lived with disability worldwide.

This guide covers:

What migraine is and how it differs from other headaches
The four phases of a migraine attack
Aura — what it is and what distinguishes it from more serious symptoms
Common triggers
How migraine is diagnosed
Acute treatments for stopping or reducing attacks
Preventive treatments for reducing attack frequency
Red flags that require urgent medical assessment

What Is Migraine?

Migraine is a primary headache disorder — a condition arising from dysfunction within the brain and nervous system itself, not caused by another underlying disease. It involves activation and sensitisation of trigeminal pain pathways and changes in cortical and brainstem function that produce the characteristic attacks.

A migraine attack is distinct from a tension headache or sinus headache. It is more severe, typically one-sided (though not always), throbbing in character, and accompanied by symptoms — nausea, vomiting, or extreme sensitivity to light (photophobia), sound (phonophobia), and sometimes smell — that make normal activity very difficult or impossible.

Migraine affects women approximately three times more often than men, a difference that emerges around puberty and reflects hormonal influences on migraine biology. It is most prevalent in the 20s–50s and can improve after menopause, though this is not universal.

The Four Phases of a Migraine Attack

A migraine attack is not simply a headache. It evolves through up to four phases, though not everyone experiences all of them:

1. Prodrome (Hours to Days Before)

Many people experience warning symptoms 6–48 hours before a headache begins:

Mood changes — irritability, low mood, or unusual euphoria
Fatigue or yawning
Food cravings (particularly for sweet or starchy foods)
Neck stiffness
Increased thirst and urination
Increased sensitivity to light or sound

Recognising prodromal symptoms allows some people to take preventive action early.

2. Aura (If Present — Typically 20–60 Minutes)

See the dedicated section below.

3. Headache Phase (4–72 Hours)

The headache of migraine is typically:

Moderate to severe in intensity
Unilateral (one-sided) in approximately 60–70% of attacks, though it can shift sides or become bilateral
Pulsating or throbbing in character
Worsened by routine physical activity (bending down, climbing stairs, walking)

Associated features that distinguish migraine from other headaches:

Nausea (in approximately 80% of attacks) and vomiting (in 30%)
Photophobia — severe light sensitivity; bright light intensifies pain
Phonophobia — severe noise sensitivity; loud sounds are intolerable
Osmophobia — sensitivity to smells (in some individuals)

During a severe attack, most people want to lie still in a dark, quiet room. Normal functioning — working, caring for children, attending commitments — is typically not possible.

4. Postdrome (Hours to a Day After)

Following the resolution of head pain, many people experience a “migraine hangover”:

Cognitive fog and difficulty concentrating
Fatigue and exhaustion
Mood changes
Generalised muscle aching

The postdrome can last 24–48 hours and contributes significantly to the overall disability of migraine.

Migraine with Aura

Aura occurs in approximately 25–30% of people with migraine. It refers to focal reversible neurological symptoms that develop gradually over several minutes and resolve fully before or shortly after the headache phase.

Visual Aura (Most Common)

The classic visual aura is a scintillating scotoma — a shimmering, zigzag arc (sometimes called a fortification spectrum) that begins near the centre of vision and slowly expands toward the visual periphery over 15–20 minutes. It may appear as flashing lights, geometric patterns, or a crescent-shaped region of blurred or absent vision.

Other visual aura types include: spots or flashes (photopsia), blurred vision, or areas of visual loss that migrate.

Sensory Aura

Tingling or numbness that spreads slowly from the hand up the arm to the face over several minutes. It may involve one side of the face and tongue. Unlike a stroke, it develops gradually (minutes, not seconds) and resolves fully.

Speech Aura (Dysphasic Aura)

Difficulty finding or producing words, occurring typically alongside visual or sensory aura. It is fully reversible and resolves with the aura.

Important: Aura vs Stroke

Aura symptoms that should trigger concern and urgent assessment:

Symptoms that develop suddenly (onset in seconds, not minutes)
Motor weakness (limb weakness, inability to lift an arm) — true motor symptoms are not typical migraine aura
Symptoms that do not fully resolve within 60 minutes
New or atypical aura in someone who has never had aura before
Aura occurring in the context of other neurological signs

When in doubt — particularly with sudden-onset symptoms or any suggestion of stroke — seek emergency assessment. Migraine aura is a diagnosis of exclusion: stroke must be ruled out, especially in a first or unusual episode.

Common Triggers

Migraine triggers are highly individual — what triggers one person’s attack may have no effect on another. Many attacks occur without any identifiable trigger. Keeping a migraine diary can help identify personal patterns.

Commonly reported triggers include:

Hormonal

Falling oestrogen levels before menstruation (menstrual migraine is common and often more severe)
Hormonal contraceptives (can improve or worsen migraine depending on type)
Perimenopause — fluctuating hormones often increase attack frequency

Sleep

Both insufficient sleep and oversleeping are common triggers
Disrupted sleep schedules (shift work, travel, weekends)

Lifestyle factors

Skipping meals or prolonged fasting
Dehydration
Stress (including the release from stress — “let-down headache”)
Intense physical exertion in some individuals

Dietary

Alcohol — particularly red wine and spirits; beer less commonly
Caffeine — either excess intake or withdrawal after regular use
Certain foods (chocolate, aged cheese, processed meats, MSG) — though the evidence for most dietary triggers is weaker than commonly believed

Sensory

Bright or flickering light, sunlight, screen glare
Strong smells — perfume, chemical fumes, cigarette smoke

Environmental

Changes in barometric pressure (weather changes)
High altitude

A note on trigger management: Eliminating all potential triggers is neither feasible nor supported by evidence. Over-avoidance can increase sensitisation and reduce quality of life. A diary-based approach to identify the most consistent personal triggers, combined with preventive treatment, is more effective than wholesale restriction.

Diagnosis

Migraine is a clinical diagnosis — it is made based on history and examination, not laboratory tests or imaging. There is no diagnostic test for migraine.

Diagnostic Criteria (International Headache Society)

Migraine without aura requires:

At least 5 attacks lasting 4–72 hours
With at least two of: unilateral location, pulsating quality, moderate-severe intensity, worsened by physical activity
With at least one of: nausea/vomiting, or photophobia and phonophobia
Not better accounted for by another diagnosis

Role of Investigation

Investigation is generally not required when:

The headache pattern is typical and consistent
Examination is normal
There are no red flag features (see below)

Investigation (brain MRI, blood tests, or lumbar puncture) is warranted when:

Headache pattern is new, rapidly worsening, or changing
Red flag features are present (see below)
Neurological examination is abnormal
Thunderclap headache occurs
Headache consistently awakens from sleep
Onset after 50 without a prior headache history

A headache diary — recording frequency, severity, duration, associated symptoms, triggers, and response to treatment — is invaluable for diagnosis and monitoring treatment response.

Acute Treatment (Stopping an Attack)

The goal of acute (abortive) treatment is to stop or substantially reduce a migraine attack. Treatment is most effective when taken early — at the first sign of headache rather than waiting for it to peak.

Step 1: Simple Analgesia

Aspirin (900 mg), ibuprofen (400 mg), or paracetamol — most effective when taken early
Adding an anti-nausea medication (metoclopramide) improves both nausea and analgesic absorption

Step 2: Triptans (Most Effective Specific Treatment)

Triptans (sumatriptan, rizatriptan, zolmitriptan, and others) are serotonin receptor agonists that specifically interrupt the migraine mechanism. They are more effective than simple analgesia for moderate to severe attacks.

Available as tablets, nasal sprays, or subcutaneous injection (faster absorption for severe or vomiting-associated attacks)
Typically most effective when taken early in the headache phase; less effective if taken during aura
Not suitable for everyone — contraindicated in people with cardiovascular disease, uncontrolled hypertension, or certain stroke subtypes
Different triptans have different pharmacokinetic profiles; if one is ineffective, another may work better

Step 3: Anti-Nausea Medications

Prochlorperazine, metoclopramide, or domperidone — useful both for nausea itself and for improving absorption of oral analgesics.

Step 4: Gepants (Newer Oral Agents)

CGRP receptor antagonists (rimegepant, ubrogepant) are newer acute treatments that are effective for attacks and, importantly, have a lower risk of medication overuse headache (MOH) than triptans or NSAIDs when used frequently.

Medication Overuse Headache — A Critical Warning

Taking acute headache medication (including triptans, NSAIDs, and paracetamol) on more than 10–15 days per month can paradoxically cause medication overuse headache (MOH) — a transformation of episodic migraine into a chronic daily or near-daily headache. This is one of the most common but underrecognised complications of migraine management.

If you are taking acute medication for headache on more than 2 days per week consistently, speak to your doctor. Preventive treatment and supervised medication withdrawal are the appropriate response.

Preventive Treatment

Preventive treatment is indicated for people with:

Frequent attacks (typically 4 or more migraine days per month)
Attacks that are severe or prolonged despite good acute treatment
Acute medication being ineffective, poorly tolerated, or contraindicated
Significant impact on quality of life or function
Medication overuse headache

Goal: Reduce attack frequency by 50% or more, reduce severity and duration, and improve responsiveness to acute treatment.

Oral Preventive Medications

Beta-blockers (propranolol, metoprolol) — well-established, good evidence, widely used
Tricyclic antidepressants (amitriptyline) — particularly useful when headache coexists with sleep disruption or chronic pain
Anticonvulsants (topiramate, valproate) — effective but topiramate has side effects (cognitive fog, weight loss, kidney stones); valproate is contraindicated in women who may become pregnant
Candesartan (an angiotensin receptor blocker) — modest evidence, good tolerability

CGRP Monoclonal Antibodies (CGRP mAbs)

The most significant advance in migraine prevention in decades. CGRP (calcitonin gene-related peptide) is a key molecule in migraine pathophysiology; these monoclonal antibodies block CGRP or its receptor.

Available agents include erenumab (Aimovig), fremanezumab (Ajovy), galcanezumab (Emgality), and eptinezumab (Vyepti). They are administered by monthly or quarterly subcutaneous injection.

Clinical trial evidence shows approximately 50% of patients achieving a 50% or greater reduction in monthly migraine days, with a favourable safety profile. They are typically used when oral preventive medications have been tried and failed, though prescribing criteria vary by health system and are evolving.

Botulinum Toxin (for Chronic Migraine)

Onabotulinumtoxin-A (Botox) injected at multiple scalp and neck sites every 3 months is an approved treatment specifically for chronic migraine (15 or more headache days per month, 8 or more of which are migraines). It requires specialist administration and is not appropriate for episodic migraine.

Migraine and Hormones

The relationship between migraine and hormonal change is clinically important:

Menstrual migraine: Attacks consistently occurring 2 days before to 3 days after the start of menstruation are common, often more severe, longer, and less responsive to treatment. Short-term preventive strategies around menstruation (triptans, NSAIDs, or transdermal oestrogen) can be effective.

Oral contraceptive pills: Combined oral contraceptives (oestrogen + progestogen) can worsen migraine in some women, particularly if they cause oestrogen withdrawal headache in the pill-free interval. Migraine with aura is a contraindication to combined oral contraceptives due to increased stroke risk — progestogen-only methods are safer alternatives.

Pregnancy: Migraine often improves significantly during the second and third trimesters due to stable oestrogen levels. Most standard migraine treatments have restrictions in pregnancy — management requires specialist input.

Perimenopause and menopause: Fluctuating hormone levels during perimenopause often worsen migraine. HRT, particularly transdermal oestrogen without pill-free breaks, may improve hormonal migraine in some women. Migraine frequently improves post-menopause when hormone levels stabilise.

For women whose migraines are clearly hormonally driven, gynaecological and neurological input may both be relevant.

Red Flags: Headaches Requiring Urgent Assessment

Not all headaches are migraine. The following features require urgent medical evaluation to rule out serious underlying conditions:

Seek emergency care immediately for:

A sudden, severe headache that reaches maximum intensity within seconds (thunderclap headache) — possible subarachnoid haemorrhage
Headache with neck stiffness, fever, or a non-blanching rash — possible meningitis
New or progressive headache in someone with cancer or immunosuppression
Headache associated with new neurological symptoms — weakness, speech change, vision loss — that do not resolve within 60 minutes
Headache following significant head trauma
Headache consistently waking from sleep
New headache in someone over 50 with no prior headache history
Rapid change in the character or frequency of an established headache pattern

Migraine with aura requires differentiation from TIA or stroke, particularly in a first or atypical episode.

FAQ

Is migraine just a bad headache?

No. Migraine is a neurological condition involving much more than head pain. Attacks include nausea, vomiting, and extreme sensitivity to light and sound. About a third of people experience aura — reversible neurological symptoms. Migraine is one of the leading causes of disability worldwide.

What is migraine with aura?

Aura refers to reversible neurological symptoms — most commonly visual disturbances (shimmering zigzag patterns or spots) — that develop gradually over 5–20 minutes before the headache. Sensory tingling and speech difficulty are less common aura types. Aura symptoms are fully reversible within an hour.

What triggers a migraine?

Triggers vary between individuals. Common triggers include hormonal changes (particularly before menstruation), sleep disruption, stress, skipping meals, dehydration, alcohol, bright light, and strong smells. Many attacks occur without a clear trigger.

Can migraines be prevented?

Yes. For frequent or disabling migraines, preventive treatment reduces attack frequency, severity, and duration. Options include daily oral medications, monthly or quarterly CGRP monoclonal antibody injections (among the most effective options available), and botulinum toxin for chronic migraine.

When should I go to hospital for a headache?

Seek emergency care for: a thunderclap headache (peak intensity within seconds), headache with neck stiffness and fever, headache with persistent neurological symptoms, headache after head trauma, or a new and rapidly changing headache pattern in someone over 50.

Are migraine and hormones connected?

Yes. Migraine is more common in women and strongly influenced by hormonal fluctuations, particularly the pre-menstrual oestrogen drop. Migraine with aura is a contraindication to combined oral contraceptives due to stroke risk. Migraine often improves during pregnancy and after menopause.