[00:00]
What if birth control isn't simply helping or worsening your migraine, but reshaping the hormonal rhythm your migraine brain is sensitive to?
[00:10]
Welcome to Migraine Heroes, a podcast for people living with chronic migraines with years of pain,
[00:17]
misunderstanding and lack of answers. I'm Diane Ducarme.
[00:20]
I've helped more than a thousand people reduce the burden of migraines and feel more in control.
[00:26]
My mission in life? To help a million people.
[00:30]
Each episode brings you grounded insight into what your body might be asking for and what can truly help.
[00:37]
Just to keep you fully supported, this podcast is educational. For diagnosis or medication,
[00:45]
always work with your doctor.
[00:47]
Now, take a breath and let's dive in.
[00:51]
In this episode, you will learn why hormonal fluctuation,
[00:55]
not simply having too much oestrogen, can matter so much and why migraines sometimes appear around
[01:01]
menstruation or during hormone-free days of birth control.
[01:05]
Why migraine with aura and migraine without aura need to be treated differently when choosing birth control,
[01:12]
especially when oestrogen-containing contraception is being considered. And what to do when your migraines appear or
[01:18]
noticeably change after starting birth control and why it's worth discussing that change early with your clinician.
[01:25]
Stay with me till the end because by the end of this episode,
[01:27]
you will know exactly what to start tracking today to understand whether your migraine pattern may be connected to your hormones or birth control.
[01:35]
So maybe you started the contraceptive pill in your teenage years and your migraine suddenly appeared for the first time or
[01:44]
they became much worse.
[01:45]
Maybe you put a hormonal coil like a Mirena IUD and at first you had plenty of energy and
[01:52]
then you started to have more frequent and more intense migraine attack. Or maybe
[01:58]
you were certain it was your hormonal contraception that introduced your migraines,
[02:03]
but then when you removed it, the migraine remained.
[02:06]
But you were certain it was the contraceptive that induced them in the first place.
[02:11]
And when you ask why, you hear several completely different explanations that do not quite resonate.
[02:17]
So if this feels confusing, there's a reason. The relationship between migraine,
[02:23]
reproductive hormones and contraception is genuinely complicated.
[02:27]
So let's dive in. The first thing is, migraine is sensitive to change.
[02:31]
So one of the most important idea to understand is that migraine does not necessarily react simply to the amount of a given hormone in the body,
[02:40]
say, oestrogen. For many people, it appears to react strongly to the change.
[02:45]
So oestrogen is going to rise and fall very naturally throughout your menstrual cycle and just before menstruation, the oestrogen level
[02:52]
falls, normally it does. And researchers have long suspected that this withdrawal can trigger migraine in susceptible people.
[03:00]
But there's a bit of an important scientific nuance here. In
[03:03]
2023, there was a review in the Journal of Headache and Pain, and they started to revisit the famous oestrogen withdrawal hypothesis.
[03:10]
And they concluded that the theory is biologically plausible and supported by several observations.
[03:16]
The direct evidence is still more limited than many people assume. And studies have often been small and inconsistent.
[03:23]
So oestrogen withdrawal should be understood as an important hypothesis rather than the single proven explanation for every menstrual migraine.
[03:31]
The distinction matters. Your migraine is not simply a hormone meter.
[03:36]
Hormones interact with so many parts of your body.
[03:38]
They interact with your nervous system, with your pain processing pathways, with your blood vessels and your
[03:44]
trigeminal system. And your trigeminal system is one of the major neurological pathways that is involved in migraine.
[03:50]
So think of hormones less like an on-off switch and more like one instrument inside a sensitive orchestra.
[03:57]
And one particularly interesting distinction in migraine is the difference between oestrogen and progesterone.
[04:02]
So both hormones naturally fall in the days leading up to menstruation, and yet research
[04:07]
suggests they may not affect the migraine brain in the same way.
[04:11]
So experiential studies have tried to separate their effects to indicate that a drop in estrogel can increase migraine susceptibility,
[04:18]
supporting that well-known oestrogen withdrawal hypothesis, whereas progesterone withdrawal does not appear to have the same effect.
[04:25]
So in fact, progesterone may have a more stabilizing influence on the nervous system. Allopregnanolone
[04:31]
enhances the activity of
[04:34]
GABA, one of the brain's main
[04:37]
inhibitory neurotransmitters, which helps quite excessive neural firing.
[04:41]
So this means progesterone may potentially reduce neuronal excitability and raise the threshold at which the migraine brain becomes
[04:49]
activated, while a rapid fall in oestrogen appears more likely to push that threshold in the opposite direction.
[04:55]
Now here's a complication.
[04:57]
Oestrogen and progesterone
[04:59]
influence one another, but not in a simple way like more progesterone equals less oestrogen type of relationship.
[05:05]
Both are controlled by the hypothalamus-pituitary-ovarian axis, and their relationship changes across the menstrual cycle.
[05:12]
So before ovulation,
[05:14]
oestrogen is the dominant hormone, and as the ovarian follicle grows, it produces increasing amounts of
[05:21]
estrogel. And when estrogel stays high enough, it helps trigger the LH surge, and then
[05:27]
ovulation. And then after ovulation, the follicle becomes the cobris luteum,
[05:31]
which produces a large amount of progesterone, as well as some oestrogen. And
[05:37]
progesterone then feeds back to the brain and pituitary, and
[05:41]
progesterone then feeds back to the brain and pituitary, and generally reduces the signals that stimulate further ovarian hormone production.
[05:48]
So progesterone can indirectly influence oestrogen production,
[05:52]
but oestrogen also helps create the conditions that allow progesterone to rise in the first place.
[05:57]
So a simple picture is this. You have your oestrogen rising, it helps trigger ovulation, then ovulation allows
[06:03]
progesterone to rise, then progesterone then helps regulate the system and suppresses further stimulation.
[06:09]
So it's a bit of a landscape. And now to make it more complex, birth control is going to change that hormonal landscape, and
[06:18]
birth control does not come in just one form.
[06:20]
There are combined hormonal contraceptives, which contain an oestrogen together with a progestin. These include certain pills,
[06:28]
patches, and vaginal rings. And there are also progestin-only
[06:32]
contraceptives, such as certain pills, injections, implants, and hormone-releasing
[06:37]
intrauterine devices. And then there are non-hormonal methods, including the copper intrauterine device.
[06:43]
So these methods can create, as you can imagine now, very different hormonal environments.
[06:49]
So that is why saying birth control gives you migraine may actually be hiding a much more useful question,
[06:56]
which hormones, at what dose, in what pattern, and what happens when those hormones rise, fall, or stop.
[07:03]
So one thing I want to mention,
[07:06]
occasionally, someone is going to tell me that their migraines began or became
[07:10]
dramatically worse, very soon after starting hormonal contraception. And if that's you,
[07:15]
I would not simply ignore what your body is telling you, and assume that you need to push through it for months.
[07:21]
Reconsider the contraception early, and discuss whether another formulation or method would suit you better.
[07:27]
I've seen women change contraception quickly, and see their migraines settle again. That's clinical experience.
[07:33]
It's not something science has proven, or analyzed, or will always happen.
[07:38]
But my impression is that when we respond early, sometimes the hormonal disturbance remains just a temporary blip,
[07:44]
rather than becoming part of a much more complicated migraine picture, that sort of follows a domino effect,
[07:50]
and then it feels like nothing's working anymore.
[07:53]
So trust yourself. Trust your intuition. Discuss with your gynecologist or doctor.
[07:58]
Now, I want to talk about the hormone-free interval. So consider the traditional combined contraceptive pill.
[08:04]
So for part of the month, you take active hormone-containing pills, or placebo days, and during those days,
[08:11]
estrogen exposure drops. And so for a migraine-sensitive nervous system, that change may matter.
[08:17]
There was a 2026 systematic review and meta-analysis, published in Curieuse, that found an important pattern.
[08:24]
When women were compared with themselves across different phases of hormonal contraceptive use,
[08:30]
migraine was more frequent during the hormone-free interval than during the active hormone phase.
[08:36]
And so the use of acute migraine medication also increased during that interval.
[08:41]
At the same time, the researchers emphasized that the available studies varied considerably,
[08:47]
and that the evidence still has important limitations.
[08:50]
So this may explain something that can otherwise seem contradictory.
[08:54]
Your birth control helps your migraine most of the time, but every placebo week, you crash.
[09:00]
And if that happens consistently, it's a really good clue.
[09:04]
The sudden withdrawal of hormones during the placebo week may be one of the things triggering your migraine.
[09:09]
So one approach, sometimes considered medically, is to shorten or to eliminate that hormone-free interval,
[09:16]
depending on the contraceptive, on your migraine type, and on your individual medical situation.
[09:21]
From a modern medical perspective, that monthly withdrawal bleed created by the pill is not considered medically necessary,
[09:28]
nor is it needed to remove toxins from the body.
[09:31]
Now, eastern medicine looks at menstruation, so not menstruation from the pill,
[09:34]
but actual menstruation through quite a different framework.
[09:37]
And for them, menstrual bleeding is understood as part of the cyclical movement and renewal of blood.
[09:42]
So completely suppressing that cycle may be viewed differently.
[09:46]
So these are two different medical frameworks, and it's useful to understand the reasoning behind each
[09:51]
and know that they have a bit of a different perspective on this.
[09:54]
Oftentimes, they converge.
[09:55]
Well, there was no contraceptive pill back then,
[09:58]
but that importance of keeping that menstruation seems very little.
[10:02]
And so you need to decide for yourself what resonates the most.
[10:05]
Then we come to ORAM, and this is really important.
[10:09]
The absolute risk of what I'm about to talk is well below 1%, so it's very rare.
[10:14]
Because the consequences can be serious, I want to mention it for your safety and also to be thorough.
[10:19]
So I want to talk about migraine with ORAM and the contraceptive pill.
[10:24]
So migraine with ORAM is independently associated with a high risk of what is called ischemic stroke.
[10:31]
So a stroke, meaning a sudden damage to part of the brain,
[10:34]
caused when a blood clot or blockage stops blood and oxygen from reaching it.
[10:40]
So that's called an ischemic stroke.
[10:42]
Again, well below 1%, but very real for some people.
[10:45]
Now, oestrogen containing combined hormonal contraceptives can increase that underlying vascular risk.
[10:52]
So there was a 2017 study in the American Journal of Obstetrics and Gynecology
[10:58]
that found that women with migraine with ORAM who used combined hormonal contraceptives
[11:03]
had approximately six times the odds of ischemic stroke compared with women who had neither factor.
[11:10]
So this is a relative increase in a very rare event.
[11:14]
So it's not a 6 in 10 chance of stroke, but it's still considerable.
[11:18]
So current U.S. contraceptive guidance therefore makes an important distinction.
[11:22]
Combined hormonal contraception is generally accepted by migraine without ORAM,
[11:27]
but is not recommended in migraine with ORAM.
[11:31]
So progestin-only methods and IUDs generally do not carry the same restriction
[11:35]
based on migraine with ORAM alone.
[11:37]
So this is why knowing whether you truly experience ORAM matters.
[11:41]
If you're not certain, you can listen to some of our podcasts on the topic,
[11:44]
and if you're not certain, discuss with your doctor,
[11:47]
or you can listen to some of our podcasts on the topic of ORAM.
[11:50]
Now, the research is not perfect, and some of the evidence comes from older observational studies,
[11:55]
but the practical message is simple.
[11:57]
Know whether you have ORAM, know which hormones your contraception contains,
[12:02]
and consider your other vascular risk factors,
[12:05]
such as smoking or high blood pressure when you're making your contraceptive choice.
[12:10]
So this is short, and this is loaded with information,
[12:13]
so if you feel this might be you, don't hesitate to listen again just to that paragraph,
[12:17]
so that you have a good idea of what we just talked about.
[12:21]
Now, what about progestin-only birth control?
[12:24]
So this is another area where people sometimes receive overly simple information.
[12:28]
So progestin-only methods are often attractive from a vascular safety perspective for people
[12:33]
with migraine with ORAM because they do not contain estrogen.
[12:36]
But that does not mean every progestin method will automatically solve migraine.
[12:40]
A 2018 systematic review and meta-analysis in Cephalalgia examined a particular progestin-only
[12:46]
pill and found modest reductions in migraine attacks and migraine days in available studies.
[12:51]
But the research has described the quality of evidence as low to very low,
[12:54]
largely because the studies were small and mostly observational.
[12:57]
So once again, we need nuance.
[12:59]
A progestin-only method may improve migraine in one person,
[13:03]
have little effect in another, and occasionally seem to worsen symptoms in someone else.
[13:07]
Your nervous system is not reading the clinical guideline,
[13:10]
it's responding to your individual biology.
[13:13]
Now there's one more connection people often miss.
[13:16]
It's migraine and medication.
[13:18]
So one preventative in particular deserves attention here.
[13:22]
So topiramide is an anti-convulsant,
[13:24]
an anti-epileptic medication used in the treatment and prevention of migraine disease.
[13:29]
And so topiramide can speed up the metabolism of some contraceptive hormones,
[13:33]
but the effect appears to depend both on the dose and on the contraceptive method.
[13:37]
So in an earlier pharmacokinetic study,
[13:40]
exposure to ethanol estrogel fell by around 18-30%
[13:45]
when topiramide was given to doses of 200-800 mg per day.
[13:50]
Although norepinephrine levels were not significantly affected.
[13:55]
And a 2022 study found a similar dose-dependent effect
[13:59]
with the ethanogestrel contraceptive implant.
[14:02]
So as topiramide was increased from 100-400 mg per day,
[14:07]
median ethanogestrel concentration fell from 142-105 pictograms per milliliter.
[14:14]
And at that 400 mg per day,
[14:16]
about 31% of participants had levels below the threshold
[14:20]
associated with consequent suppression of ovulation.
[14:23]
So this is one to watch out for.
[14:25]
Now, there is also some reassuring real-world evidence
[14:29]
for the lower doses more commonly used in migraine.
[14:32]
A 2023 study examined 63,500 episodes of women with migraine or chronic headache
[14:39]
taking oral contraceptives together with topiramide.
[14:42]
And the unintended pregnancy rate was 1.3 per 100% years.
[14:47]
So exactly the same as in women taking oral contraceptives
[14:51]
with other migraine preventatives.
[14:52]
So the researchers concluded that low dose topiramide,
[14:55]
so up to 200 mg per day,
[14:57]
was not associated with an increased risk of contraceptive failure.
[15:00]
So this is not a reason to panic if you take topiramide.
[15:03]
It's a reason to make sure that whoever is prescribing your migraine medication
[15:08]
also knows which contraceptive you use.
[15:11]
Because the dose and the type of contraception matter.
[15:15]
So the CDC, the Centers for Disease Control and Prevention,
[15:18]
so the main federal public health agency in the United States,
[15:21]
still advises particular caution with topiramide
[15:24]
and combined hormonal contraceptives or progestin monopiles,
[15:28]
while methods such as IUDs and contraceptive injections
[15:32]
are not effective in the same way.
[15:33]
So this is an example of why migraine care cannot live in isolated boxes.
[15:39]
Your neurologist sees your head,
[15:40]
your gynecologist sees your hormones,
[15:43]
but you live in one body and that body connects everything.
[15:46]
Now let's go east.
[15:47]
In the eastern perspective, hormones are not just levels,
[15:51]
And traditional Chinese medicine developed
[15:53]
long before anyone identified estrogen or progesterone,
[15:56]
so practitioners were obviously not talking about hormones
[16:00]
in the biochemical way we do today.
[16:02]
But what is interesting is that Chinese medicine
[16:04]
paid enormous attention to the cyclical nature of female physiology.
[16:08]
Foods and herbs were used differently at different stages of the menstrual cycle
[16:12]
with the aim of supporting what the body was trying to do
[16:15]
at that particular moment.
[16:16]
And modern science has revealed an intriguing overlap.
[16:19]
So soy, for example, contains isoflavones,
[16:22]
often called phytoestrogens,
[16:25]
because they can interact with estrogen receptors.
[16:27]
Some plants also contain tiny amounts of progesterone
[16:30]
or compounds capable of interacting with progesterone receptors.
[16:34]
So our ancestors were not secretly prescribing estrogen and progesterone,
[16:38]
but they were working empirically with plants
[16:40]
that we now know can interact with some of the same biological pathways.
[16:45]
There's another fascinating historical connection with the yam.
[16:48]
So certain wild yams contain diosgenin,
[16:51]
a plant steroid that becomes an important raw material
[16:54]
for the pharmaceutical production of steroid hormones.
[16:57]
So in the laboratory, chemists can transform diosgenin
[17:01]
into hormones such as progesterone.
[17:03]
But for me, the most interesting part of Eastern perspective
[17:06]
is not the individual food.
[17:08]
Another interesting part of the Eastern perspective is the rhythm.
[17:12]
In Chinese medicine, the menstrual cycle can be understood
[17:15]
as a continuous movement between yin and yang.
[17:17]
So after menstruation, yin and blood are relatively depleted
[17:21]
and begin to rebuild.
[17:23]
And so during the follicular phase, yin gradually grows.
[17:26]
Around ovulation, yin reaches a point of fullness
[17:30]
and transforms into yang.
[17:32]
And during the luteal phase, yang becomes relatively more dominant,
[17:35]
supporting warmth, activity, and preparing for possible pregnancy.
[17:39]
Then if pregnancy does not occur, that yang phase must give way again
[17:44]
and blood moves, menstruation begins, and another cycle starts.
[17:48]
And this waxing and waning of yin and yang
[17:51]
is a recognized framework in contemporary Chinese medicine gynecology.
[17:55]
And this is where it becomes particularly interesting for margarine,
[17:58]
because from a traditional Chinese medicine perspective,
[18:00]
you do not necessarily want more upwinding.
[18:03]
You want enough yin to contain and anchor yang,
[18:05]
and you want the transition between the two to happen smoothly.
[18:09]
If yin has become insufficient, yang may become relatively unanchored
[18:13]
as you approach menstruation.
[18:15]
It can rise upward.
[18:16]
And in that framework, this may present as heat, irritability,
[18:19]
disturbed sleep, tension, throbic headaches, and migraine
[18:22]
around that premenstrual period.
[18:24]
So simply thinking, my oestrogen is low, therefore I need more oestrogen,
[18:27]
may be too simplistic.
[18:29]
And the opposite, I have too much oestrogen,
[18:31]
therefore oestrogen is bad for me, can be too simplistic as well.
[18:34]
Modern migraine science is actually moving us
[18:36]
toward a similar dynamic idea.
[18:38]
Margarine appears to respond not simply to the absolute amount of oestrogen,
[18:42]
but as we talked about, in response to the changes in oestrogen over time.
[18:46]
Falling oestrogen around menstruation has long been associated
[18:49]
with menstrual migraine, although the evidence for oestrogen withdrawal
[18:52]
as the sole mechanism is not complete.
[18:55]
And at the other end of the spectrum,
[18:56]
higher oestrogen states can influence aura in some people.
[19:00]
Now that gives us a useful meeting point between the two systems.
[19:04]
The question may not simply be, do I have too much oestrogen
[19:08]
or too little oestrogen?
[19:09]
The better question may be, what is the rhythm?
[19:12]
How high does it rise?
[19:13]
How quickly does it fall?
[19:15]
And how well is my nervous system adapting to that transition?
[19:18]
And that's particularly relevant when we introduce birth control,
[19:21]
because contraception does not simply add a hormone.
[19:24]
Depending on the method, it can flatten, suppress, replace,
[19:28]
or abruptly interrupt part of our natural hormonal rhythm.
[19:31]
And for a migraine brain that is particularly sensitive to change,
[19:35]
sometimes the transition itself may be as important as the level.
[19:40]
So what can you start today in your home?
[19:42]
You can start by creating a simple hormone and migraine map.
[19:46]
You can track your cycle, contraceptive days, or hormone-free interval.
[19:49]
You can track your bleeding, possible aura, your migraine timing and intensity,
[19:53]
your sleep, your meals, your unusual stress.
[19:56]
And you can do all of this directly in the Migraine Heroes app.
[19:58]
So while we offer paid support, the tracking itself can also be used free of charge.
[20:04]
And you can bring or print your records for your doctor or neurologist,
[20:07]
giving them something much more useful than simply saying,
[20:11]
I think my migraines are a hormone now.
[20:13]
So this is about becoming a force for your own well-being.
[20:16]
The more clearly you can see what's happening inside your body,
[20:19]
the more control you can give again.
[20:21]
And again, I can't emphasize enough, this is a complicated podcast.
[20:25]
It's loaded with different realities and different situations.
[20:28]
So don't hesitate to listen to it again and try to start to map in your mind,
[20:33]
in which categories do you belong among everything that we've discussed together.
[20:37]
That's all for today.
[20:39]
I hope this episode added another piece to your migraine puzzle.
[20:43]
If you'd like to apply what we've discussed to your own life,
[20:46]
you can find us by searching Migraine Heroes in the App Store or Google Play.
[20:51]
Look for the green icon with the love heart in the brain.
[20:55]
Migraine is complex, but it's not random.
[20:58]
And every step forward brings us closer to lasting relief.
[21:01]
Your body has a story to tell.
[21:03]
Let's keep listening.
[21:04]
I will be back with you soon.
