Menstrual migraine: hormones and attacks you can predict

“I know when it will come. The day before my period, or the first day. Every month. And every month I still behave as if it has taken me by surprise.”

Many women who have lived with migraine for years could describe their calendar like this. The sentence is not about the pain — women like this can tell you everything about the pain. It is about something else: having an illness that tells you in advance when it will arrive, and still wrecks your week every time. Meetings postponed at exactly that point. A friend’s birthday where she turns up pale again and is the first to leave. A partner who asks anew each month whether it might be better for her to stay at home.

Menstrual migraine is mostly written about as a hormonal matter. And it is one. But the predictability it brings has another side — a psychological one, and a relational one. That is what I want to write about here: what is happening in the body, why that part belongs with a neurologist and a gynaecologist, and what you can do yourself with the fact that you can see an attack coming.

First of all: migraine is a neurological disease

I need to say this at the start, because women with menstrual migraine are often brushed aside twice. First the old way: “You get headaches because you’re tense.” Then the newer way: “That’s just women’s problems.” Neither is true. Migraine is a neurological disease with known mechanisms in the brain and nervous system, a hereditary component and fairly precise diagnostic criteria. It is not an expression of suppressed emotions, it is not a psychosomatic symptom and it is not a matter of character.

When I wrote about when the body really does carry an emotional load, in “The tests are normal, but it still hurts”, I was dealing with a completely different question. With migraine there is no need to look for a hidden psychological explanation. Psychological work with migraine does not explain why it hurts; it helps with how you live with the fact that it hurts — and sometimes with how often.

Why does this matter for menstrual migraine in particular? Because here shame and dismissal double. Migraine is already an invisible illness. When it is also tied to menstruation, which many women still do not talk about openly, it becomes doubly invisible.

How many women this affects

Migraine is markedly a women’s disease. In a large American population study (Lipton et al., 2007), about 17 per cent of women and just under 6 per cent of men had migraine — almost three times as many women. The difference appears after puberty; before it, migraine is roughly equally common in boys and girls. That alone hints that sex hormones play a part.

An analysis of the global burden of disease (Steiner et al., 2020) placed migraine among the leading causes of years lived with disability, and in first place for women under fifty. These are the years when a woman is building a career, caring for small children, perhaps for ageing parents — and when her cycle is at its most regular.

For many women with migraine, attacks are linked to menstruation. A smaller group has attacks only then; most also have them on other days, but more often around their period. The distinction is not merely academic — it shapes what a doctor will suggest.

What happens in the body

In the second half of the cycle, oestrogen stays relatively high for a while and then drops steeply in the last days before menstruation. It is this drop — not the low level itself — that is considered the main trigger. The neurologist Brian Somerville showed this back in the early 1970s: when he gave women with menstrual migraine oestradiol before their period, the attack was delayed, but menstruation was not. Oestrogen postponed the headache, not the bleeding.

Besides oestrogen, prostaglandins probably play a role too — substances released from the lining of the womb at the start of bleeding, which are also linked to menstrual cramps. So for some women, attacks on these days are part of a wider package: cramps, tiredness, poorer sleep, irritability.

When we call a migraine menstrual

The International Classification of Headache Disorders (ICHD-3) has specific criteria for menstrual migraine. An attack has to begin in the window from two days before the first day of bleeding to the third day after it, in at least two out of three consecutive cycles. The classification distinguishes two forms:

• pure menstrual migraine, where attacks happen only in this window, and
• menstrually related migraine, where attacks also happen on other days, but there are more of them around menstruation.

The classification explicitly recommends confirming this with a diary kept as you go, over at least three cycles. Memory is a poor judge here. When the pain is severe it seems to be “always” then, and once it passes you forget the attack that came mid-cycle. I have described how to keep a diary without it draining too much energy in A migraine diary: why it works and how to keep one.

Studies that followed women day by day found something else too: for many, attacks around menstruation are longer and more severe than attacks on other days, and respond less well to medication (MacGregor & Hackshaw, 2004; Granella et al., 2004). If you feel that “those” attacks are different, you are probably not imagining it.

Diagnosis and medication belong with your doctor

I will keep this short, because it is not my field and it would not be right for it to be. A diagnosis is made by a doctor — your GP, a neurologist or a headache clinic. Treating menstrual migraine is specific: there are acute medications, short-term prevention around the predictable days and hormonal approaches. Talk to a neurologist and a gynaecologist about what suits you, ideally in a way that each knows about the other.

Two things I can say without a medical degree, because every set of guidelines stresses them:

• Do not start, stop or change hormonal contraception or hormonal treatment on your own because of migraine. With some forms of migraine, especially migraine with aura, the choice of hormonal preparations calls for careful consultation. Always tell your gynaecologist that you have migraine, and what kind.
• If your attacks change — they are suddenly different or worse, new symptoms appear, or a headache has started for the first time after the age of fifty — see a doctor and do not wait for the next cycle.

Everything that follows complements medical care; it does not replace it.

Predictability: a gift and a burden at once

Most people with migraine live with uncertainty: an attack can come at any time. Compared with them, a woman with menstrual migraine has an advantage. She knows when it will come. That lets her plan, prepare and, together with her doctor, act in time.

But that same predictability can also become a burden. For some women, the migraine does not start on the first day of bleeding but several days earlier — in their head. Glancing at the calendar. Counting the days. Cancelling things that are still far off. Tension that builds because “it’s going to happen again this week”. This is anticipatory anxiety, and in migraine it has its own name and its own research. I have written more about it, and about why it so often accompanies migraine, in Migraine and anxiety: why they so often go together.

There is an important difference between preparation and anticipation. Preparation is concrete: the medication is in your bag, Friday’s dinner has been moved, your manager knows. Once it is done, your thoughts can go elsewhere. Anticipation has no end. It prepares nothing; it only lives the attack in advance. One task of psychological work is to strengthen the first and let go of the second.

There is another trap that comes with the attack itself: out of fear of the pain, a woman sometimes reaches for painkillers earlier and earlier, and more and more often. Frequent use of painkillers can itself make headaches worse, so how often you take them is something to discuss with your doctor — not something you sort out on your own with more tablets.

Those days are not only a headache

An attack does not arrive in an empty space. For many women, mood dips before menstruation anyway, irritability rises and sleep becomes shallower. When migraine joins in, the week can feel like one long bad day. It is not unusual for other premenstrual difficulties to accompany migraine — it all unfolds against the same hormonal fluctuation.

Poor sleep plays a double role here. On the one hand, changes in sleep are a common attack trigger for many people with migraine. On the other, after a bad night we tolerate everything less well — pain included, and each other included. I wrote about why in Sleep and emotion: why everything hurts more after a bad night. So one of the least noticeable but most useful steps in the week before your period is protecting your sleep: a regular bedtime, fewer late evenings you would otherwise “catch up on”.

If your mood drops so much before your period each month that it damages your relationships or your work, or you have thoughts that nothing makes sense, tell your doctor. Premenstrual dysphoric disorder exists; it is more than “bad PMS” and it can be treated. If the thoughts are severe and happening now, call the Klic v duševni stiski helpline on 01 520 99 00 in Slovenia (7 pm to 7 am) or the Samarijan helpline on 116 123 in Slovenia (every day, 24 hours).

What menstrual migraine does to relationships

Because I work in family therapy, with any chronic illness I am interested in what happens around the person, not only inside them. With menstrual migraine, similar patterns often repeat.

Invisibility. Because the cause is tied to menstruation, women rarely talk about it directly. At work they say “headache”, at home “I feel unwell”, to friends “I can’t”. Those around them see only cancelled plans, not the pattern behind them. And because they do not see the pattern, they cannot take it into account.

Guilt. Many women resent themselves for “once again” not managing. Some apologise every month, as though it were something they could have prevented. Guilt does not reduce the pain, but it does increase tension — and tension does not help.

The family story. Because migraine is hereditary, a mother or grandmother often had it too. Along with the genes, attitudes are passed on: “The women in our family just suffer and keep quiet.” “Mum still cooked lunch when she had a headache.” Sentences like these are not medical facts, but they are very powerful family rules about how pain should be carried. Once a woman recognises them, she can choose which ones to keep. The genogram drawing tool can help when exploring patterns like these across generations.

Here is a short conversation that shows how differently the same month can sound once the pattern has been named (composed, not a real person):

“Shall we go to your parents’ next Friday?”
“Can we look at the calendar? Friday is exactly the day before my period. It won’t necessarily be an attack, but it’s likely.”
“Ah. Saturday a week later, then?”
“Yes. And if one does come unannounced, I’ll tell you early, not at the last minute.”
“Fine. Just tell me what you need then — for me to leave you in peace, or to be there.”

It is not a dramatic conversation. That is exactly its value: the migraine becomes shared information rather than private shame, and the partner moves from helpless onlooker to someone who knows what they can do.

What is in your hands

The medical side of menstrual migraine is clear: diagnosis, medication, any hormonal aspects. The psychological side is less visible, but it rests on well-researched ground. Meta-analyses show that relaxation techniques, biofeedback and cognitive behavioural approaches reduce the frequency of migraine attacks (Nestoriuc & Martin, 2007). They do not replace medication, but they work alongside it.

With menstrual migraine these techniques have a particular advantage: you can practise them in a targeted way. Not the same all year round, but with an emphasis on the days when your system is most vulnerable. There is one important rule: you do not learn relaxation in the middle of an attack. You learn it on calm days, so that your body knows it when it needs it. A good start is progressive muscle relaxation, one of the most researched techniques for headaches, or simply breathing with a longer out-breath.

Stress is a special case in migraine, because an attack often does not come in the middle of the pressure but when it eases. The body often gives way only when it allows itself to breathe out. For menstrual migraine this leads to a practical tip: if you can, do not schedule the biggest deadline of the month right before your predictable days. Not because stress would “make you ill”, but because two loads add up.

Exercise: a plan for the predictable days

You can do this exercise today, with a notebook and a calendar. It takes about fifteen minutes, and then a few minutes a month.

1. Mark the window. Write the expected first day of your next period in your calendar and mark the two days before it and the three days after. If you keep a diary, check whether the window matches your attacks.
2. Separate the essential from the movable. Look at what you have planned for those days. For each item, ask: can I move it, hand it over or make it lighter? Do not cancel everything — only what would hurt most during an attack.
3. Prepare once, not every day. Make a list of what you need during an attack (medication as your doctor has advised, water, a dark room, who takes over with the children). Once the list is made, allow yourself not to think about it every day.
4. Say it in advance. Choose one person — your partner, a colleague, a friend — and tell them that these days are vulnerable for you and what you need then. One sentence is enough.
5. Notice the anticipation. When, in the days before the window, you catch yourself already living through the attack in your mind, say to yourself: “It’s prepared. Now I’m here.” Then go back to what you were doing. If that doesn’t work, do a few minutes of breathing with a longer out-breath.

After three months, look back: are the attacks different? Are the days before them different? Often it is the latter that changes before the pain does — the weight of the week leading up to it.

Where this approach is not enough

I want to be honest here. Psychological work with menstrual migraine does not remove hormonal fluctuation and does not replace treatment. For some women the attacks are so severe that no preparation makes the week bearable — here the answer lies first with a neurologist, perhaps at a headache clinic, not in more diligent breathing.

Equally, not every migraine around menstruation is menstrual migraine. If your diary shows that attacks are spread across the whole month, the window matters less than you think, and it makes more sense to look for other patterns. And if you also have anxiety that grows outside that window, it is worth taking it seriously as a topic of its own — Health anxiety: when every symptom means the worst looks at how fear of symptoms can spread.

And finally: even the best plan does not guarantee that an attack will come at the expected time. Cycles change — with stress, after giving birth, in the years before menopause. For many women migraine settles during pregnancy, while in the years before menopause it can get worse for a while. So let the plan be flexible, not one more rule you can “break”.

What to remember

• Migraine is a neurological disease, not a psychosomatic symptom and not “female weakness”. Menstrual migraine is a form of it, linked to the drop in oestrogen.
• We speak of menstrual migraine when attacks begin from two days before to three days after bleeding starts in at least two of three cycles — confirmed by a diary over at least three cycles.
• Diagnosis, medication and anything hormonal belong with a neurologist and gynaecologist. Do not change anything on your own.
• Predictability is an advantage if we turn it into preparation, and a burden if it becomes anticipation.
• Relaxation and cognitive behavioural approaches are a well-researched complement; practise them on calm days, not in the middle of an attack.