Migraine
Cyclical migraines: why attacks land with your period
Every month, like clockwork: two days before your period arrives, so does the migraine. If that pattern sounds familiar, you are describing one of the most under-recognised conditions in women’s health, and one of the most dismissed.
Women are two to three times more likely than men to live with migraine. For a significant group the attacks are wired to the menstrual cycle. Around 6% of women of reproductive age experience menstrual migraine.[1] Many have never heard the term. Fewer still have been offered treatment designed for it.
Menstrual migraine is real, and measurably worse
This is not “just a headache with your period”. Menstrual attacks behave differently: research shows they last up to 35% longer, tend to be more disabling, and respond less well to standard acute treatment, with symptoms more likely to return after medication.[1] A major review in The Lancet Neurology described menstrual migraine as a distinct disorder that needs far greater recognition than it gets.[2] If your period migraines feel worse than your other migraines, that is not imagination. It is the documented pattern.
What causes it? The honest answer
The leading explanation is oestrogen withdrawal. In the days before a period, oestrogen falls sharply, and in susceptible women that drop appears to trigger an attack. The theory dates to elegant experiments in the 1970s, where giving oestrogen delayed the migraine but not the period, and it remains the dominant model.
The evidence deserves honest handling. Recent reviews point out that the studies behind the hypothesis are smaller and less conclusive than the textbooks suggest, and researchers are still working out exactly how falling oestrogen interacts with the brain’s pain pathways.[1] What is not in doubt is the clinical pattern: the perimenstrual window is a genuinely high-risk time for attacks.
In clinic, not all “cyclical migraines” are the same. While oestrogen withdrawal explains a good proportion, I will sometimes attribute the pattern instead to progesterone and the GABA-receptor threshold. That is why “hormonal” migraines need an individual formulation, not a single slogan.
First step: prove the pattern
The diagnosis is made with a diary, not a scan. Track attacks and your cycle for three months (an app or paper both work). Menstrual migraine means attacks reliably landing in the window from about a week to two or three days before your period, in at least two out of three cycles. That diary turns “I think they’re hormonal” into evidence that unlocks specific treatment.
What actually helps
Because menstrual attacks are predictable, treatment can be too. Short courses of a long-acting triptan taken around menstruation have been shown in randomised trials to prevent or blunt menstrual attacks,[3] and this approach is used in UK practice for women whose attacks are predictable.
In my view that treats the end issue, not always the driving cause. Lifestyle and precision medicine are where the formulation can change.
Beyond the perimenstrual window, lifestyle measures have real evidence: regular aerobic exercise reduces migraine days in meta-analyses of trials,[4] and strength training performed even better in a network meta-analysis comparing exercise types.[5] Steady routines matter because migraine brains dislike change: consistent sleep, regular meals and managed stress all raise the trigger threshold.
In clinic I take a deep-dive history and use lifestyle medicine and precision health to narrow the cause. Each root cause deserves its own plan.
One safety point I want every reader to hear, because it sits in my specialty: if you have migraine with aura and you take the combined contraceptive pill, that combination needs reviewing. UK guidance classifies it as unacceptable risk because both independently raise the risk of stroke and blood clots.[6] There are excellent alternatives. Please do not simply stop contraception; book a proper review.
If you are in perimenopause and your migraines are changing or worsening, that is expected biology. Fluctuating oestrogen is a hard pattern for a migraine brain, and it changes the treatment conversation, including how HRT is chosen and delivered.
Where this fits
Cyclical migraine is rarely an isolated issue. In clinic it is usually woven together with sleep, stress load, hormonal stage and metabolic health, which is why a ten-minute appointment so often fails it. Piecing that picture together (with your diary, your history and the right tests) is the work of the Women’s Health Package at The Richmond House Clinic.
This article is general education, not personal medical advice. Please speak to your own doctor about your situation.
References
- Raffaelli B, et al. Menstrual migraine is caused by estrogen withdrawal: revisiting the evidence. J Headache Pain. 2023. PMID: 37730536.
- MacGregor EA, et al. Menstrual migraine: a distinct disorder needing greater recognition. Lancet Neurol. 2021.
- Silberstein SD, et al. A randomized trial of frovatriptan for the intermittent prevention of menstrual migraine. Neurology. 2004.
- Lemmens J, et al. The effect of aerobic exercise on the number of migraine days, duration and pain intensity in migraine: a systematic review and meta-analysis. J Headache Pain. 2019.
- Woldeamanuel YW, Oliveira ABD. What is the efficacy of aerobic exercise versus strength training in the treatment of migraine? A systematic review and network meta-analysis. J Headache Pain. 2022.
- Faculty of Sexual & Reproductive Healthcare. UK Medical Eligibility Criteria for Contraceptive Use (UKMEC).