Migraine is three times more common in women than in men. This difference is rooted in fluctuations in sex hormones. Migraine attacks increase with puberty, are linked to the menstrual cycle, change during pregnancy, return after delivery, and reshape themselves again with menopause.
The menstrual cycle plays a determining role in migraine. Estrogen levels drop rapidly before menstruation. This drop triggers migraine attacks in some women. This pattern, known as catamenial migraine, tends to be more severe, longer-lasting, and less responsive to painkillers than other migraine attacks. During pregnancy, when estrogen levels remain high, attacks generally decrease. In about eight percent of pregnant women, however, migraine worsens or appears for the first time, most often in the form of migraine with aura. Even in women whose migraine attacks decrease during pregnancy, this effect is limited to the pregnancy period, and attacks often return in the early postpartum period as estrogen drops sharply.
Migraine increases certain risks during pregnancy. Women with migraine have twice the risk of preeclampsia compared with those without migraine. The risk of preterm birth also increases. In pregnant women with migraine, the risk of stroke can rise up to eightfold, and this risk is particularly pronounced in migraine with aura (5,7,8,10-12). For this reason, pregnant women with migraine, especially those with aura, need to be closely monitored throughout pregnancy.
Migraine treatment during pregnancy relies primarily on non-pharmacological approaches. Avoiding triggers, regular sleep, a balanced diet, adequate fluid intake, and physical activity are recommended. Neuromodulation devices may also be considered a safe option in certain situations. However, severe migraine should not be left untreated, and medication is used when necessary. Acetaminophen is the first choice for acute attacks. Certain painkillers can be used with caution during the second trimester. Among the medications used for acute migraine treatment, sumatriptan is the only one with sufficient data on use during pregnancy. When preventive treatment is needed, beta blockers such as propranolol and metoprolol, along with amitriptyline, stand out. Topiramate and valproate are not preferred for migraine treatment during pregnancy. Women receiving preventive treatment with these medications who are planning to become pregnant need to discontinue treatment a certain period before pregnancy.
Data on newer medications targeting the CGRP pathway remain limited when it comes to pregnancy. These drugs can cross the placental barrier. For this reason, they are recommended to be avoided during pregnancy and in the period when pregnancy is being planned. Women receiving preventive treatment with these medications who are planning to become pregnant need to discontinue treatment a certain period before pregnancy.
During breastfeeding, medication choice is also made taking into account the amount of drug passed to the infant. Acetaminophen is the first choice. Sumatriptan and eletriptan can be preferred due to their low transfer into breast milk. Beta blockers and amitriptyline can also be used with caution.
The course of migraine during menopause is variable. During the transition period when estrogen levels fluctuate, attacks increase in some women. After menopause, once estrogen settles at a low and stable level, migraine improves in many women. This once again demonstrates the relationship between migraine attacks and sudden changes in hormone levels.
This close link between migraine and hormones requires that the treatment plan for women patients be shaped according to their life stage. The menstrual cycle, pregnancy planning, pregnancy, breastfeeding, and menopause each require separate consideration. For this reason, it is important for women with migraine, especially those of reproductive age, to remain in regular communication with their physicians.
References
1-Ornello R, Maassen van den Brink A, Puledda F, et al. Migraine management during pregnancy, breastfeeding and in women planning pregnancy. Cephalalgia 2025;45(11):1-21.
2-Purdue-Smithe AC, Stuart JJ, Farland LV, et al. Prepregnancy migraine, migraine phenotype, and risk of adverse pregnancy outcomes. Neurology 2023;100:e1464-e1473.
3-Bandoli G, Baer RJ, Gano D, et al. Migraines during pregnancy and the risk of maternal stroke. JAMA Neurol 2020;77:1177-1179.
