Migraine, Hormones & Birth Control: Making Sense of the Connection

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What if birth control isn't simply helping or worsening your migraine, but reshaping the hormonal rhythm your migraine brain is sensitive to?

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Welcome to Migraine Heroes, a podcast for people living with chronic migraines with years of pain,

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misunderstanding and lack of answers. I'm Diane Ducarme.

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I've helped more than a thousand people reduce the burden of migraines and feel more in control.

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My mission in life? To help a million people.

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Each episode brings you grounded insight into what your body might be asking for and what can truly help.

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Just to keep you fully supported, this podcast is educational. For diagnosis or medication,

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always work with your doctor.

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Now, take a breath and let's dive in.

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In this episode, you will learn why hormonal fluctuation,

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not simply having too much oestrogen, can matter so much and why migraines sometimes appear around

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menstruation or during hormone-free days of birth control.

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Why migraine with aura and migraine without aura need to be treated differently when choosing birth control,

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especially when oestrogen-containing contraception is being considered. And what to do when your migraines appear or

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noticeably change after starting birth control and why it's worth discussing that change early with your clinician.

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Stay with me till the end because by the end of this episode,

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you will know exactly what to start tracking today to understand whether your migraine pattern may be connected to your hormones or birth control.

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So maybe you started the contraceptive pill in your teenage years and your migraine suddenly appeared for the first time or

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they became much worse.

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Maybe you put a hormonal coil like a Mirena IUD and at first you had plenty of energy and

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then you started to have more frequent and more intense migraine attack. Or maybe

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you were certain it was your hormonal contraception that introduced your migraines,

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but then when you removed it, the migraine remained.

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But you were certain it was the contraceptive that induced them in the first place.

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And when you ask why, you hear several completely different explanations that do not quite resonate.

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So if this feels confusing, there's a reason. The relationship between migraine,

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reproductive hormones and contraception is genuinely complicated.

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So let's dive in. The first thing is, migraine is sensitive to change.

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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,

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say, oestrogen. For many people, it appears to react strongly to the change.

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So oestrogen is going to rise and fall very naturally throughout your menstrual cycle and just before menstruation, the oestrogen level

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falls, normally it does. And researchers have long suspected that this withdrawal can trigger migraine in susceptible people.

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But there's a bit of an important scientific nuance here. In

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2023, there was a review in the Journal of Headache and Pain, and they started to revisit the famous oestrogen withdrawal hypothesis.

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And they concluded that the theory is biologically plausible and supported by several observations.

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The direct evidence is still more limited than many people assume. And studies have often been small and inconsistent.

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So oestrogen withdrawal should be understood as an important hypothesis rather than the single proven explanation for every menstrual migraine.

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The distinction matters. Your migraine is not simply a hormone meter.

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Hormones interact with so many parts of your body.

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They interact with your nervous system, with your pain processing pathways, with your blood vessels and your

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trigeminal system. And your trigeminal system is one of the major neurological pathways that is involved in migraine.

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So think of hormones less like an on-off switch and more like one instrument inside a sensitive orchestra.

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And one particularly interesting distinction in migraine is the difference between oestrogen and progesterone.

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So both hormones naturally fall in the days leading up to menstruation, and yet research

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suggests they may not affect the migraine brain in the same way.

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So experiential studies have tried to separate their effects to indicate that a drop in estrogel can increase migraine susceptibility,

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supporting that well-known oestrogen withdrawal hypothesis, whereas progesterone withdrawal does not appear to have the same effect.

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So in fact, progesterone may have a more stabilizing influence on the nervous system. Allopregnanolone

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enhances the activity of

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GABA, one of the brain's main

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inhibitory neurotransmitters, which helps quite excessive neural firing.

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So this means progesterone may potentially reduce neuronal excitability and raise the threshold at which the migraine brain becomes

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activated, while a rapid fall in oestrogen appears more likely to push that threshold in the opposite direction.

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Now here's a complication.

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Oestrogen and progesterone

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influence one another, but not in a simple way like more progesterone equals less oestrogen type of relationship.

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Both are controlled by the hypothalamus-pituitary-ovarian axis, and their relationship changes across the menstrual cycle.

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So before ovulation,

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oestrogen is the dominant hormone, and as the ovarian follicle grows, it produces increasing amounts of

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estrogel. And when estrogel stays high enough, it helps trigger the LH surge, and then

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ovulation. And then after ovulation, the follicle becomes the cobris luteum,

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which produces a large amount of progesterone, as well as some oestrogen. And

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progesterone then feeds back to the brain and pituitary, and

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progesterone then feeds back to the brain and pituitary, and generally reduces the signals that stimulate further ovarian hormone production.

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So progesterone can indirectly influence oestrogen production,

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but oestrogen also helps create the conditions that allow progesterone to rise in the first place.

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So a simple picture is this. You have your oestrogen rising, it helps trigger ovulation, then ovulation allows

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progesterone to rise, then progesterone then helps regulate the system and suppresses further stimulation.

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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

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birth control does not come in just one form.

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There are combined hormonal contraceptives, which contain an oestrogen together with a progestin. These include certain pills,

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patches, and vaginal rings. And there are also progestin-only

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contraceptives, such as certain pills, injections, implants, and hormone-releasing

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intrauterine devices. And then there are non-hormonal methods, including the copper intrauterine device.

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So these methods can create, as you can imagine now, very different hormonal environments.

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So that is why saying birth control gives you migraine may actually be hiding a much more useful question,

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which hormones, at what dose, in what pattern, and what happens when those hormones rise, fall, or stop.

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So one thing I want to mention,

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occasionally, someone is going to tell me that their migraines began or became

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dramatically worse, very soon after starting hormonal contraception. And if that's you,

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I would not simply ignore what your body is telling you, and assume that you need to push through it for months.

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Reconsider the contraception early, and discuss whether another formulation or method would suit you better.

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I've seen women change contraception quickly, and see their migraines settle again. That's clinical experience.

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It's not something science has proven, or analyzed, or will always happen.

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But my impression is that when we respond early, sometimes the hormonal disturbance remains just a temporary blip,

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rather than becoming part of a much more complicated migraine picture, that sort of follows a domino effect,

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and then it feels like nothing's working anymore.

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So trust yourself. Trust your intuition. Discuss with your gynecologist or doctor.

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Now, I want to talk about the hormone-free interval. So consider the traditional combined contraceptive pill.

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So for part of the month, you take active hormone-containing pills, or placebo days, and during those days,

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estrogen exposure drops. And so for a migraine-sensitive nervous system, that change may matter.

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There was a 2026 systematic review and meta-analysis, published in Curieuse, that found an important pattern.

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When women were compared with themselves across different phases of hormonal contraceptive use,

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migraine was more frequent during the hormone-free interval than during the active hormone phase.

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And so the use of acute migraine medication also increased during that interval.

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At the same time, the researchers emphasized that the available studies varied considerably,

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and that the evidence still has important limitations.

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So this may explain something that can otherwise seem contradictory.

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Your birth control helps your migraine most of the time, but every placebo week, you crash.

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And if that happens consistently, it's a really good clue.

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The sudden withdrawal of hormones during the placebo week may be one of the things triggering your migraine.

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So one approach, sometimes considered medically, is to shorten or to eliminate that hormone-free interval,

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depending on the contraceptive, on your migraine type, and on your individual medical situation.

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From a modern medical perspective, that monthly withdrawal bleed created by the pill is not considered medically necessary,

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nor is it needed to remove toxins from the body.

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Now, eastern medicine looks at menstruation, so not menstruation from the pill,

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but actual menstruation through quite a different framework.

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And for them, menstrual bleeding is understood as part of the cyclical movement and renewal of blood.

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So completely suppressing that cycle may be viewed differently.

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So these are two different medical frameworks, and it's useful to understand the reasoning behind each

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and know that they have a bit of a different perspective on this.

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Oftentimes, they converge.

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Well, there was no contraceptive pill back then,

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but that importance of keeping that menstruation seems very little.

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And so you need to decide for yourself what resonates the most.

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Then we come to ORAM, and this is really important.

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The absolute risk of what I'm about to talk is well below 1%, so it's very rare.

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Because the consequences can be serious, I want to mention it for your safety and also to be thorough.

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So I want to talk about migraine with ORAM and the contraceptive pill.

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So migraine with ORAM is independently associated with a high risk of what is called ischemic stroke.

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So a stroke, meaning a sudden damage to part of the brain,

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caused when a blood clot or blockage stops blood and oxygen from reaching it.

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So that's called an ischemic stroke.

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Again, well below 1%, but very real for some people.

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Now, oestrogen containing combined hormonal contraceptives can increase that underlying vascular risk.

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So there was a 2017 study in the American Journal of Obstetrics and Gynecology

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that found that women with migraine with ORAM who used combined hormonal contraceptives

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had approximately six times the odds of ischemic stroke compared with women who had neither factor.

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So this is a relative increase in a very rare event.

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So it's not a 6 in 10 chance of stroke, but it's still considerable.

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So current U.S. contraceptive guidance therefore makes an important distinction.

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Combined hormonal contraception is generally accepted by migraine without ORAM,

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but is not recommended in migraine with ORAM.

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So progestin-only methods and IUDs generally do not carry the same restriction

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based on migraine with ORAM alone.

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So this is why knowing whether you truly experience ORAM matters.

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If you're not certain, you can listen to some of our podcasts on the topic,

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and if you're not certain, discuss with your doctor,

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or you can listen to some of our podcasts on the topic of ORAM.

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Now, the research is not perfect, and some of the evidence comes from older observational studies,

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but the practical message is simple.

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Know whether you have ORAM, know which hormones your contraception contains,

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and consider your other vascular risk factors,

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such as smoking or high blood pressure when you're making your contraceptive choice.

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So this is short, and this is loaded with information,

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so if you feel this might be you, don't hesitate to listen again just to that paragraph,

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so that you have a good idea of what we just talked about.

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Now, what about progestin-only birth control?

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So this is another area where people sometimes receive overly simple information.

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So progestin-only methods are often attractive from a vascular safety perspective for people

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with migraine with ORAM because they do not contain estrogen.

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But that does not mean every progestin method will automatically solve migraine.

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A 2018 systematic review and meta-analysis in Cephalalgia examined a particular progestin-only

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pill and found modest reductions in migraine attacks and migraine days in available studies.

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But the research has described the quality of evidence as low to very low,

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largely because the studies were small and mostly observational.

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So once again, we need nuance.

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A progestin-only method may improve migraine in one person,

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have little effect in another, and occasionally seem to worsen symptoms in someone else.

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Your nervous system is not reading the clinical guideline,

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it's responding to your individual biology.

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Now there's one more connection people often miss.

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It's migraine and medication.

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So one preventative in particular deserves attention here.

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It's topiramide.

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So topiramide is an anti-convulsant,

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an anti-epileptic medication used in the treatment and prevention of migraine disease.

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And so topiramide can speed up the metabolism of some contraceptive hormones,

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but the effect appears to depend both on the dose and on the contraceptive method.

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So in an earlier pharmacokinetic study,

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exposure to ethanol estrogel fell by around 18-30%

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when topiramide was given to doses of 200-800 mg per day.

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Although norepinephrine levels were not significantly affected.

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And a 2022 study found a similar dose-dependent effect

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with the ethanogestrel contraceptive implant.

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So as topiramide was increased from 100-400 mg per day,

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median ethanogestrel concentration fell from 142-105 pictograms per milliliter.

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And at that 400 mg per day,

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about 31% of participants had levels below the threshold

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associated with consequent suppression of ovulation.

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So this is one to watch out for.

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Now, there is also some reassuring real-world evidence

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for the lower doses more commonly used in migraine.

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A 2023 study examined 63,500 episodes of women with migraine or chronic headache

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taking oral contraceptives together with topiramide.

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And the unintended pregnancy rate was 1.3 per 100% years.

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So exactly the same as in women taking oral contraceptives

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with other migraine preventatives.

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So the researchers concluded that low dose topiramide,

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so up to 200 mg per day,

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was not associated with an increased risk of contraceptive failure.

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So this is not a reason to panic if you take topiramide.

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It's a reason to make sure that whoever is prescribing your migraine medication

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also knows which contraceptive you use.

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Because the dose and the type of contraception matter.

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So the CDC, the Centers for Disease Control and Prevention,

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so the main federal public health agency in the United States,

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still advises particular caution with topiramide

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and combined hormonal contraceptives or progestin monopiles,

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while methods such as IUDs and contraceptive injections

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are not effective in the same way.

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So this is an example of why migraine care cannot live in isolated boxes.

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Your neurologist sees your head,

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your gynecologist sees your hormones,

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but you live in one body and that body connects everything.

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Now let's go east.

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In the eastern perspective, hormones are not just levels,

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they are rhythms.

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And traditional Chinese medicine developed

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long before anyone identified estrogen or progesterone,

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so practitioners were obviously not talking about hormones

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in the biochemical way we do today.

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But what is interesting is that Chinese medicine

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paid enormous attention to the cyclical nature of female physiology.

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Foods and herbs were used differently at different stages of the menstrual cycle

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with the aim of supporting what the body was trying to do

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at that particular moment.

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And modern science has revealed an intriguing overlap.

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So soy, for example, contains isoflavones,

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often called phytoestrogens,

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because they can interact with estrogen receptors.

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Some plants also contain tiny amounts of progesterone

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or compounds capable of interacting with progesterone receptors.

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So our ancestors were not secretly prescribing estrogen and progesterone,

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but they were working empirically with plants

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that we now know can interact with some of the same biological pathways.

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There's another fascinating historical connection with the yam.

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So certain wild yams contain diosgenin,

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a plant steroid that becomes an important raw material

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for the pharmaceutical production of steroid hormones.

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So in the laboratory, chemists can transform diosgenin

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into hormones such as progesterone.

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But for me, the most interesting part of Eastern perspective

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is not the individual food.

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Another interesting part of the Eastern perspective is the rhythm.

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In Chinese medicine, the menstrual cycle can be understood

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as a continuous movement between yin and yang.

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So after menstruation, yin and blood are relatively depleted

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and begin to rebuild.

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And so during the follicular phase, yin gradually grows.

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Around ovulation, yin reaches a point of fullness

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and transforms into yang.

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And during the luteal phase, yang becomes relatively more dominant,

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supporting warmth, activity, and preparing for possible pregnancy.

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Then if pregnancy does not occur, that yang phase must give way again

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and blood moves, menstruation begins, and another cycle starts.

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And this waxing and waning of yin and yang

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is a recognized framework in contemporary Chinese medicine gynecology.

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And this is where it becomes particularly interesting for margarine,

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because from a traditional Chinese medicine perspective,

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you do not necessarily want more upwinding.

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You want enough yin to contain and anchor yang,

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and you want the transition between the two to happen smoothly.

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If yin has become insufficient, yang may become relatively unanchored

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as you approach menstruation.

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It can rise upward.

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And in that framework, this may present as heat, irritability,

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disturbed sleep, tension, throbic headaches, and migraine

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around that premenstrual period.

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So simply thinking, my oestrogen is low, therefore I need more oestrogen,

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may be too simplistic.

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And the opposite, I have too much oestrogen,

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therefore oestrogen is bad for me, can be too simplistic as well.

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Modern migraine science is actually moving us

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toward a similar dynamic idea.

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Margarine appears to respond not simply to the absolute amount of oestrogen,

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but as we talked about, in response to the changes in oestrogen over time.

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Falling oestrogen around menstruation has long been associated

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with menstrual migraine, although the evidence for oestrogen withdrawal

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as the sole mechanism is not complete.

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And at the other end of the spectrum,

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higher oestrogen states can influence aura in some people.

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Now that gives us a useful meeting point between the two systems.

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The question may not simply be, do I have too much oestrogen

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or too little oestrogen?

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The better question may be, what is the rhythm?

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How high does it rise?

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How quickly does it fall?

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And how well is my nervous system adapting to that transition?

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And that's particularly relevant when we introduce birth control,

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because contraception does not simply add a hormone.

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Depending on the method, it can flatten, suppress, replace,

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or abruptly interrupt part of our natural hormonal rhythm.

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And for a migraine brain that is particularly sensitive to change,

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sometimes the transition itself may be as important as the level.

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So what can you start today in your home?

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You can start by creating a simple hormone and migraine map.

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You can track your cycle, contraceptive days, or hormone-free interval.

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You can track your bleeding, possible aura, your migraine timing and intensity,

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your sleep, your meals, your unusual stress.

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And you can do all of this directly in the Migraine Heroes app.

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So while we offer paid support, the tracking itself can also be used free of charge.

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And you can bring or print your records for your doctor or neurologist,

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giving them something much more useful than simply saying,

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I think my migraines are a hormone now.

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So this is about becoming a force for your own well-being.

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The more clearly you can see what's happening inside your body,

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the more control you can give again.

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And again, I can't emphasize enough, this is a complicated podcast.

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It's loaded with different realities and different situations.

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So don't hesitate to listen to it again and try to start to map in your mind,

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in which categories do you belong among everything that we've discussed together.

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That's all for today.

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I hope this episode added another piece to your migraine puzzle.

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If you'd like to apply what we've discussed to your own life,

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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.

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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.

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Let's keep listening.

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I will be back with you soon.