Neurology and Women's Health 2021: Migraine

Gender has profound, complex effects across all fields of health, and neurology is no exception. Biological differences such as sex hormones across the life cycle affect the symptoms and onset of Alzheimer’s, multiple sclerosis, and other conditions. Cultural mores mean that women do most of the caregiving for loved ones with Alzheimer’s disease, even as they are at greater risk than men for developing the condition. Even history plays a part, as for generations women have been left out of clinical trials.

For Women’s History Month 2021, the Duke Neurology and Neurosurgery Department will be sharing a series of articles discussing the intersections of women’s health and neurological and neurosurgical conditions. Today, neurologist and headache specialist Jaskiran Vidwan, DO, will be discussing migraines, which are three times as common among women as they are among men. Vidwan discusses some of the reasons why migraines are more frequent, how symptoms differ between men and women, and how migraines affect women at various stages of their lives. Finally Vidwan discusses therapies that can help women and men cope with migraines and advances in treatment we may see in the next several years.

What are migraines, and how do they differ from other forms of headache?

Migraines are distinguished from other headache disorders based on their features. Migraines are recurring headaches that involve moderate to severe pain that is typically on one side of the head. These headaches are disabling and may be worsened by routine physical activity. They are associated with light and sound sensitivity and/or nausea or vomiting and may last for 4-72 hours when untreated.

What are some of the differences in how migraines affect women and men? 

Women are more likely to suffer from migraines than men. Of the 39 million Americans that have migraine, 28 million are women. And while the general characteristics of a migraine are the same for both genders, migraine attacks may last longer in women and be more intense in severity than in men. Women are also more likely to have greater disability (e.g., difficulty functioning and continuing normal activities) during a migraine attack.

What are the reasons behind these gender differences?
We do not know the exact reason why migraines affect women more than men. However, it is widely believed to be due to hormone changes that occur in a woman’s life. Young women tend to develop migraines around the time they start menstruating. We see an increase in migraines during other times of hormonal fluctuations such as after childbirth or during perimenopause.

What treatments are available to help women with migraines?
The treatment for migraine is interchangeable between men and women. These can include lifestyle changes (e.g. sleeping well, stress reduction, etc.), migraine diets, vitamins, medications, injections, and devices. The big difference is hormone therapy could also be considered in some women to reduce their migraine frequency. 

In addition to the symptoms they cause directly, what kinds of effects do migraines have on women’s lives? What are some effective strategies for alleviating this impact?

In women, the prevalence of migraine peaks in the mid-30’s and sharply declines after menopause. This has a huge impact on a woman’s life because it coincides with a time when she is furthering her career or growing her family. As such, migraines can be very disabling and have adverse impacts on a woman’s goals. Fortunately, migraine treatments are designed to mitigate this burden. There are also acute and preventative pharmacologic and nonpharmacologic treatment options for migraine.  

What gender gaps or disparities (if any) are there in how we diagnose, treat, or research migraine? What can be done to help alleviate these disparities?
Overall, migraine is largely underdiagnosed and undertreated condition across both genders. This is partly due to misdiagnosis or patients not seeking medical care for what they may consider to be just a bad headache. Women are more likely to see a healthcare provider regarding their migraines than men. Men tend to underreport their symptoms, possibly because migraine has long been considered a “woman’s disease.” Sadly, there is still a large stigma associated with migraine.

There needs to be continued education on the provider front and community awareness about the prevalence, impact, and treatment options for migraine. There are several organizations, such as Miles for Migraine and Coalition for Headache and Migraine Patients, that are expanding migraine education, treatment access, advocacy for patients, and are working to legitimize this disabling neurologic condition.  

Even though women are three times more likely to get migraine, there is a lack of research and understanding of this difference. We need more studies that account for gender to better optimize migraine treatment and perhaps develop gender specific recommendations.

What advances in how we treat or understand migraines do you see coming in the next five to 10 years, and how will those advances help people living with migraines?

For years, the management of migraine has centered on antihypertensives, anticonvulsants, antidepressants, or Botox injections. While these therapies can be highly effective, none were designed specifically for use in migraine. In the past two years, we have made groundbreaking progress with the development of calcitonin gene related peptide (CGRP) blocking medications. By targeting CGRP, a major protein that is released during a migraine attack, we can effectively treat migraine. Moving forward, as our understanding of the mechanism of migraine grows, we will be able to develop more migraine specific medications. There is also growing interest in the role of transient receptor potential (TRP) channels in the migraine pathway. These channels could serve as another target for future therapeutics.

What’s one thing you wished more women with migraines knew?
Migraine is not just a headache. It is a neurologic disorder and deserves the same type of understanding from your healthcare provider, employers, friends, and family as other disorders of the body. There are many safe and effective treatments for migraine and many more on the horizon. There are resources and support groups to help women who are suffering from migraine – you are not alone.