Cluster headache in women: relation with menstruation, use of oral contraceptives, pregnancy, and menopause (2023)

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  • J Neurol Neurosurg Psychiatry
  • v.77(5); 2006 May
  • PMC2117457

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Cluster headache in women: relation with menstruation, use of oral contraceptives, pregnancy, and menopause (1)

Journal of Neurology, Neurosurgery and PsychiatryVisit this articleSubmit a manuscriptReceive email alertsContact usBMJ

J Neurol Neurosurg Psychiatry. 2006 May; 77(5): 690–692.

Published online 2006 Jan 11. doi:10.1136/jnnp.2005.081158

PMCID: PMC2117457

PMID: 16407458

J A van Vliet, I Favier, F M Helmerhorst, J Haan, and M D Ferrari

(Video) Migraines, Menstruation and Menopause #celebratemuliebrity

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Abstract

In contrast with migraine, little is known about the relation between cluster headache and menstrual cycle, oral contraceptives, pregnancy, and menopause. A population based questionnaire study was performed among 224 female cluster headache patients, and the possible effect of hormonal influences on cluster headache attacks studied. For control data, a similar but adjusted questionnaire was sent to healthy volunteers and migraine patients. It was found that menstruation, use of oral contraceptives, pregnancy, and menopause had a much smaller influence on cluster headache attacks than in migraine. Cluster headache can, however, have a large impact on individual women, for example to refrain from having children.

Keywords: cluster headache, menstruation, oral contraceptives, pregnancy, menopause

Cluster headache (CH) is a severe primary headache disorder accompanied with autonomic symptoms.1 It has long been regarded as a “male dominant” disease, but male preponderance seems to decrease in recent years.2,3 In contrast with migraine, which seems to be influenced by hormonal fluctuations in many women,4 little is known about the influence of hormonal factors like menstruation, use of oral contraceptives, pregnancy, and menopause on CH. The aim of this study was to investigate whether these factors influenced CH episode characteristics.

Methods

All neurologists (about 560) and general practitioners (about 5800) in the Netherlands were asked to invite CH or CH‐like patients to join the study. Patients could also register on a Dutch CH web site. A screening questionnaire based on the International Headache Society (IHS) criteria for CH was used to verify the diagnosis in each patient.5 Because the study started before 2004, patients were diagnosed according to the 1988 IHS criteria.6

Patients

All female patients above the age of 18 fulfilling IHS criteria for CH were asked to fill in a questionnaire, including items about onset of headache, age at first menstruation, duration of menstrual cycle, use of oral contraceptives (not specified whether it was oestrogen containing), pregnancies, menopause, and the influence of these events on frequency and severity of headache attacks. Patients were classified as episodic or chronic CH.

Controls

CH patients were asked to approach a friend, colleague, or neighbour without CH or migraine to serve as healthy control. A number of questions in the questionnaire for controls checked the presence of CH or other headache syndromes. The questionnaire was also sent to 384 women with migraine with or without aura, randomly recruited from a migraine database at our department (n>1200).

Definitions

Ovulatory menstrual cycle was defined as a regular cycle with a duration varying between 21 to 35 days between the first day of two succeeding menstruations.7 Menopause was defined as at least one year amenorrhoea.

(Video) Migraine in Perimenopause and Menopause

Menstruation related migraine was defined as attacks occurring more often, but not exclusively, during menstruation. Pure menstrual migraine was defined as attacks occurring exclusively during the two days preceding or following the first day of menstruation.8

Statistics

Data were stored in a database (MS Access) and analysed using SPSS software. We used relative risks (RR), χ2 test, and t test for comparisons, and considered p<0.05 as significant. Data are expressed as RR (95% confidence interval (95% CI)), as mean (SD) or as n (%).

Results

Of 224 women with CH, 196 (88%) responded, as did 211 of the 384 (55%) migraine patients and 189 healthy controls. Seven of the healthy controls seemed to have migraine according to the IHS criteria and were excluded. None had CH.

Demographics

Current age of migraine patients (43.9 years (SD 11.6)) tended to be lower than that of CH patients (47.3 years (SD 13.1), p = 0.05). Age at onset of CH was higher (32.3 years (SD 15.2)) compared with migraine (18.1 years (SD 9.2), p<0.001). The age at menarche did not differ between groups.

Menarche and menstrual cycle (table 1​1)

Table 1 Influence of menstruation, use of oral contraceptives, pregnancy, and menopause on cluster headache attacks

Cluster headache n = 196Migraine n = 211RR (95% CI)Healthy controls n = 182RR (95% CI)
Menstruation
Headache before menarche7 (4)74 (35)
Non‐ovulatory menstrual cycle12 (6)26 (12)0.50 (0.26 to 0.96)11 (6)1.01 (0.46 to 2.24)
Increased episode severity during menstruation17 (9)55 (26)0.33 (0.20 to 0.55)
Oral contraceptives (OC)
Number using OC169190
Increase of headache frequency and/or severity using OC20 (12)54 (28)
Decrease of headache frequency and/or severity using OC7 (4)21 (11)
Pregnancy
Number ever pregnant143 (73)147 (70)1.05 (0.93 to 1.18)136 (75)0.98 (0.87 to 1.10)
Increase of headache severity during pregnancy3 (2)7 (5)0.44 (0.12 to 1.67)
Increase of headache frequency during pregnancy2 (1)10 (7)0.21 (0.05 to 0.92)
⩾1 miscarriage48 (34)54 (37)0.91 (0.67 to 1.25)29 (21)1.57 (1.06 to 2.34)
Menopause
Number in menopause64 (33)47 (22)1.47 (1.06 to 2.02)35 (19)1.70 (1.12 to 2.43)
Increase of headache severity during menopausal transition7 (9)16 (25)0.32 (0.14 to 0.72)
Increase of headache frequency during menopausal transition8 (10)32 (51)0.18 (0.09 to 0.36)
Hysterectomy and/or ovariectomy22 (11)11 (5)2.15 (1.07 to 4.32)7 (4)2.92 (1.28 to 6.67)

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Data are mean (SD) or n (%) and RR (95% CI). RR is relative risk of CH patients compared with migraine patients and CH patients compared with healthy volunteers.

During menstruation mean CH episode frequency was not increased (3.0 (SD 1.9) attacks/day) compared with the non‐bleeding period of the cycle (3.1 (SD 2.6) attacks/day). Severity of CH episodes was increased in 17 (9%) women during their menstruation.

Menstruation related migraine was reported by 141 (67%), and pure menstrual migraine was reported by four (2%) patients.

(Video) Hormone Therapy to Reduce Severity of Menstrual Migraines

CH patients reported less frequently an increase of attack severity during their menstruation compared with migraine patients (RR 0.33 (95% CI 0.20 to 0.55)).

Use of oral contraceptives (table 1​1)

Oral contraceptives were ever used by 169 women with CH, of whom 20 (12%) reported an increase of headache after starting. Seven patients (4%) reported an improvement. A total of 190 migraine patients had ever used oral contraceptives, 54 (28%) experienced increase of headache, 21 (11%) reported a decrease.

Pregnancy (table 1​1)

The mean number of children did not differ between groups. Fifty three of the 143 CH patients who had ever been pregnant had their first attacks before the first pregnancy, 89 had the first episodes after the first pregnancy. One patient had the first attacks during the first pregnancy. Twenty six of 111 (23%) episodic CH patients who had been pregnant reported that an “expected” cluster period did not occur during pregnancy. In eight of these a cluster period started within one month after delivery.

Nineteen patients had had CH attacks during a pregnancy. Of these, 11 reported no increase in severity or frequency compared with attacks outside pregnancy. Three patients reported improvement of the attacks, the remaining five patients reported increased attack frequency and/or severity during pregnancy.

Patients who did not have children at the onset of CH (n = 53) had significantly fewer children (mean 1.8 (SD 1.0) children) than those who had their first CH attack after their first pregnancy (n = 89, mean 2.3 (SD 0.9) children, p<0.01). Twenty three patients intentionally had no children: seven reported that having CH was the reason.

In 63 (43%) migraine patients, the attacks were absent during pregnancy, and returned within one month after delivery in 29 of them. Three patients had their first migraine attack during a pregnancy. There were no differences in the number of children between migraine patients who were nullipara during their first attack, and patients who had their first attack after the first pregnancy. Nine patients, of 22 who had no children intentionally, reported that the reason for not having children was migraine.

Menopause (table 1​1)

CH started during or after menopausal transition in 47 (24%) patients. Of the patients who were in menopause during the study (n = 64), 9% reported increased severity of attacks and 10% increased frequency of attacks.

In migraine patients, headaches started before menopausal transition in 209 (99%) patients.

Migraine patients more often reported increased severity (RR 0.32 (95% CI 0.14 to 0.72)) and frequency (RR 0.18 (95% CI 0.09 to 0.36)) of attacks than CH patients during menopausal transition. Five of the 47 migraine patients who were in menopause during the study reported that the headache had decreased in severity, five other reported a decrease in frequency and two patients reported that the attacks had completely stopped.

Discussion

In this study we found that menstruation, use of oral contraceptives, pregnancy, and menopause had a limited influence on attack characteristics in CH patients in general, a finding that was also found by an earlier study.3 There were, however, clear examples of the impact of CH on the particpants.

CH during pregnancy may be difficult to treat, as the only treatment that is permitted during pregnancy is inhalation of 100% oxygen, which is effective in about 70% of attacks.9 We found that patients who had their first attack before their first pregnancy had fewer children than those who already had children at the time of their first CH attack. This was also found in an earlier study.10 Apparently, the prospect of having to stop effective treatment can be a reason for some women to give up the idea of having (more) children. In contrast, 26 (23%) patients with episodic CH stated to have had no attack during pregnancy, although they had expected such a period. It is not sure if this is caused by the episodic nature of CH or by a possible hormonal influence that resulted in delay of that particular cluster period. To our knowledge, no prospective studies have been performed that would inform us about the intra‐individual reliability of “predicting” a cluster period.

There are some limitations of this study. Firstly, the data were obtained retrospectively by questionnaire. This can be a particular problem studying features such as menstruation, as 33% of CH women already were in menopause and may not have remembered menstruation related phenomena in detail. Another limitation concerns the fact that no information was gathered about the exact headache characteristics (frequency, severity) before and after menarche, before and during oral contraceptive use, before and during pregnancy, and before and after menopause. Although this is a limitation, this information would also be prone to be distorted by recall bias and can only be reliable obtained through prospective studies.

Furthermore, the number of responders to the questionnaires in the migraine group was rather low. The reason for this low response may have been that pregnancies or menstruation occurred too long ago. However, to our knowledge this is the first study concerning the influence of menstruation, oral contraceptives, pregnancy, and menopause in a large population based sample of CH women.

(Video) Womens Wellness: What women need to know about migraines

Acknowledgements

We thank L Bollen, M Zwinkels en A Douma for their help in conducting this study. This study was performed on behalf of the Dutch RUSSH research group.

Footnotes

Funding: JAvV is sponsored by the Asclepiade foundation

Competing interests: none declared

References

1. Headache Classification Subcommittee of the International Headache Society The international classification of headache disorders. Cephalalgia 200424(suppl 1)9–160. [PubMed] [Google Scholar]

2. Manzoni G C. Male preponderance of cluster headache is progressively decreasing over the years. Cephalalgia 199737588–589. [PubMed] [Google Scholar]

3. Bahra A, May A, Goadsby P J. Cluster headache. A prospective clinical study with diagnostic implications. Neurology 200258354–361. [PubMed] [Google Scholar]

4. Johannes C B, Linet M S, Stewart W F.et al Relationship of headache to phase of the menstrual cycle among young women. A daily diary study. Neurology 1995451076–1082. [PubMed] [Google Scholar]

5. van Vliet J A, Eekers P J E, Haan J.et al Features involved in the diagnostic delay of cluster headache. J Neurol Neurosurg Psychiatry 2003741123–1125. [PMC free article] [PubMed] [Google Scholar]

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7. Taylor P J, Collins J A. The physiology and investigation of ovulation. In: Unexplained infertility. Oxford: Oxford University Press, 199220

8. MacGregor E A. “Menstrual” migraine: towards a definition. Cephalalgia 19961611–21. [PubMed] [Google Scholar]

9. Fogan L. Treatment of cluster headache. A double blind comparison of oxygen v air inhalation. Arch Neurol 198542362–363. [PubMed] [Google Scholar]

(Video) Perimenopausal migraines: Why they happen and how you can stop them!

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Articles from Journal of Neurology, Neurosurgery, and Psychiatry are provided here courtesy of BMJ Publishing Group

FAQs

Are cluster headaches linked to menopause? ›

The hormone changes that happen as women approach the menopause mean that all types of headache, including migraines, become more common. Hormone replacement therapy (HRT) can be helpful to treat hot flushes and sweats.

Can birth control cause cluster headaches? ›

The estrogen in combination birth control can cause a sudden flurry in headache or migraine activity, but they tend to subside as your body gets used to the increased overall hormone levels.

Can hormonal changes cause cluster headaches? ›

Other studies have suggested an association between cluster headache and hormonal fluctuations, with the report of more severe CH attacks during the menstrual period, a tendency toward the improvement during pregnancy and a possible negative effect of oral contraception and hormonal replacement therapy (5, 15, 16).

What is the cause of cluster headaches? ›

Doctors do not know exactly what causes cluster headaches. They seem to be related to the body's sudden release of histamine (chemical in the body released during an allergic response) or serotonin (chemical made by nerve cells) in the area of a nerve in the face called the trigeminal nerve.

What conditions mimic cluster headaches? ›

Other headaches that resemble cluster headaches include SUNCT (short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing) and paroxysmal hemicranias. Cluster headache may also resemble some secondary headaches notably trigeminal neuralgia, temporal arteritis, and sinus headaches.

Can age 50 menopause symptoms cause headaches? ›

Headaches are more common around menopause due to fluctuating hormone levels. If you have had headaches in the past – especially if you get migraines – you may notice menopause headaches are more frequent or more severe.

What vitamin deficiency causes cluster headaches? ›

Patients with cluster headache have been reported to have low vitamin D levels, although the relevance of this finding is not clear.

What gets rid of cluster headaches? ›

Acute treatments
  • Oxygen. Briefly inhaling pure oxygen through a mask provides dramatic relief for most who use it. ...
  • Triptans. The injectable form of sumatriptan (Imitrex), which is commonly used to treat migraine, is also an effective treatment for acute cluster headache. ...
  • Octreotide. ...
  • Local anesthetics. ...
  • Dihydroergotamine.

Is there a way to stop cluster headaches? ›

A medicine called verapamil is the main treatment for preventing cluster headaches. It's taken as a tablet several times a day. Verapamil can cause heart problems in some people, so while taking it you'll need to be monitored using a test called an electrocardiogram (ECG).

What does a menopause headache feel like? ›

Signs and symptoms include an intense pulsing or throbbing type of pain, often on one side of the head, as well as symptoms such as flashing lights or "aura", sensitivity to light, nausea and vomiting. To help ease menopause migraines, make sure you eat regularly, stay hydrated and manage stress.

What hormonal changes are associated with headaches? ›

A headache can be triggered any time there is a fluctuation in estrogen levels, including when there is a dip in estrogen levels around the time of your menstrual cycle. Women may also experience more headaches around the start of menopause and when they undergo hysterectomy.

Are cluster headaches triggered by stress? ›

Cluster headache is a strictly unilateral headache that occurs in association with autonomic symptoms. Stress is a recognised precipitant of migraines, but not of cluster attacks. We describe the case of a patient having migraine for years, in whom extreme emotional stress triggered cluster headache attacks.

What is the difference between a migraine and a cluster headache? ›

A migraine is severe pain or throbbing, typically on one side of the head. Cluster headaches are painful headaches that are shorter in duration but recur over a period of a few months and are followed by a period of remission up to a few years.

What is worse cluster headaches or migraines? ›

Migraines tend to build up slowly and last a long time. If left untreated, it can stick around for up to 72 hours. Symptoms can impact daily life, but migraines are considered less intense than a cluster headache.

Are cluster headaches neurological? ›

Cluster headache is a neurological disorder that presents with unilateral severe headache associated with ipsilateral cranial autonomic symptoms. Cluster headache attacks often occur more than once a day, and typically manifesting in bouts.

What are the two types of cluster headaches? ›

Cluster headache can be episodic or chronic:
  • episodic cluster headache – bouts last from 7 days to one year separated by pain free periods lasting at least 3 months. ...
  • chronic cluster headache – persistent attacks for more than a year without remission, or remission lasts less than three months.

Why does oxygen stop cluster headaches? ›

4,5,6 Although pure oxygen inhalation is recognized as the first-line treatment, the underlying pathophysiology is still unclear. It has been observed that vasodilation is accompanied with CH attacks and studies have suggested oxygen aborted headaches by contracting the cerebral vessels.

Can low estrogen cause headaches during menopause? ›

A drop in the female hormone, estrogen, can also set off migraines. That's why women who get migraines often have headaches right before their period, when estrogen levels are low. During pregnancy, estrogen levels rise, bringing many women a break from these headaches.

What are the symptoms of low estrogen? ›

Symptoms of low estrogen can include:
  • Hot flashes, flushes, and night sweats are the most common symptoms of low estrogen. At times, blood rushes to your skin's surface. ...
  • Mood swings are another effect of low estrogen. You may feel sad, anxious, or frustrated. ...
  • Thinning tissues may cause discomfort.

What is the best treatment for menopause headaches? ›

We recommend using medications with dual benefit for migraine and vasomotor symptoms including venlafaxine, escitalopram, paroxetine, and gabapentin, as well as non-medication strategies such as acupuncture, vitamin E, black cohosh, aerobic exercise, and yoga.

Does magnesium help with cluster headaches? ›

A study involving 22 patients with cluster headaches who were treated with magnesium sulphate 1g found that 41% of patients reported 'meaningful relief' (defined as complete cessation of attacks or relief for more than 3 days) after treatment (Mauskop et al., 1995).

Does B12 help with cluster headaches? ›

Studies have suggested that B6, B9, and B12 can reduce the severity and frequency of migraine attacks.

Can magnesium deficiency cause cluster headaches? ›

Magnesium deficiency may occur for several reasons, such as inadequate intake or increased gastrointestinal or renal loss. A large body of literature suggests a relationship between magnesium deficiency and mild and moderate tension-type headaches and migraines.

Does drinking water help cluster headaches? ›

Dehydration can trigger (cause) a migraine headache. If you get migraines, it's essential to drink plenty of water. Staying hydrated may help you prevent a migraine attack.

What vitamin helps with cluster headaches? ›

Many studies revealed that vitamin D supplementation had an impact on reducing headache frequency, especially for migraine.

Which doctor to consult for cluster headache? ›

Cluster headaches are usually treated by either a neurologist or a headache specialist.

How does melatonin help cluster headaches? ›

During cluster periods, the timing and peak of endogenous melatonin release can become blunted or even absent812—exogenous melatonin supplementation may help by restoring these rhythms. Alternatively melatonin's benefit may be mediated through improved sleep in some headache disorders.

What does a hormone headache feel like? ›

A menstrual migraine (or hormone headache) starts before or during a woman's period and can happen every month. Common symptoms include a dull throbbing or severe pulsing headache, sensitivity to light, nausea, fatigue, dizziness and more.

Why are headaches after 50 bad? ›

Older Age. If you are older than 50 and experience a new or progressive headache, it may be giant cell arteritis or a brain tumor.

What is a natural remedy for hormonal headaches? ›

Treatment for hormonal headaches
  1. Drink plenty of water to stay hydrated.
  2. Lie down in a dark, quiet room.
  3. Place an ice bag or cold cloth to your head.
  4. Massage the area where you feel pain.
  5. Perform deep breathing or other relaxation exercises.

Does magnesium help with menstrual migraines? ›

Daily oral magnesium has also been shown to prevent menstrually related migraine, especially in those with premenstrual migraine. This means that preventive use can target those with aura or those with menstrually related migraine, even for those with irregular cycles.

Where are menstrual headaches located? ›

A hormonal migraine is much like any other type of migraine. You may notice: Aura before the headache (not everyone gets this) Throbbing pain on one side of your head.

How do you get rid of a menstrual headache? ›

What are some remedies I can use for menstrual migraine?
  1. Hot or cold compresses. Here's an inexpensive remedy that's effective at reducing migraine and menstrual pain: hot and cold compresses. ...
  2. Ginger tea. ...
  3. Essential oils. ...
  4. CBD. ...
  5. Acupressure. ...
  6. Birth control. ...
  7. Prescription medications. ...
  8. Supplements.

How do you break a cluster headache cycle? ›

There is no cure for cluster headaches. You can't do anything to prevent a cycle of cluster headaches from starting. But as soon as a cycle starts, you can take medicine that may help prevent more headaches or reduce how many you have during a cycle. You take this medicine every day during the cycle.

Why do cluster headaches happen at night? ›

Melatonin is normally secreted by the pineal gland based on input from the suprachiasmatic nucleus of the hypothalamus which, in turn, responds to changing levels of environmental light. Cluster headache patients have impaired melatonin production with less melatonin produced particularly during bouts [71].

Are cluster headaches caused by trauma? ›

Nerve injury is suggested as the mechanism by which trauma could initiate cluster headache. Cluster headache is a distinctive headache syndrome generally thought to be due to vasodilatation. In contrast to migraine, hereditary factors are not important.

Which patient is more likely to have a cluster headache? ›

Most people who develop cluster headaches are between ages 20 and 50, although the condition can develop at any age. Smoking. Many people who get cluster headache attacks are smokers.

What is Sunct syndrome? ›

SUNCT (also known as Short-lasting, Unilateral, Neuralgiform headache attacks with Conjunctival injection and Tearing) is a rare form of headache that is marked by bursts of moderate to severe burning, piercing, or throbbing pain, usually on one side of the head and around the eye or temple.

What is the pain level of cluster headaches? ›

Cluster headache pain is more intense than any other pain disorder we examined at 9.7, with the next most painful disorder, labor pain at 7.2, a full 2.5 points less on a 0–10 scale.

What does a pre menopause headache feel like? ›

What Do Perimenopause Headaches Feel Like? Perimenopause headaches typically present as a throbbing pain on one side of your head. You may also experience sensitivity to light and sound. The good news is that these headaches are not usually debilitating and can be well controlled with treatment.

Can menopause cause ice pick headaches? ›

Oestrogen is thought to cause blood vessels to dilate, while progesterone causes them to tighten. As the level of these hormones fluctuate, the blood vessels are constantly expanding and contracting. This causes pressure changes in the head, resulting in painful headaches.

How do you get rid of menopause headaches? ›

We recommend using medications with dual benefit for migraine and vasomotor symptoms including venlafaxine, escitalopram, paroxetine, and gabapentin, as well as non-medication strategies such as acupuncture, vitamin E, black cohosh, aerobic exercise, and yoga.

Does low estrogen cause headaches? ›

Headaches, especially migraine headaches, have been linked to the female hormone estrogen. Estrogen controls chemicals in the brain that affect the sensation of pain. A drop in estrogen levels can trigger a headache.

What is the best supplement for menopause headaches? ›

Vitamin B complex

Improving your resilience to stress is also likely to have a positive impact on the frequency and duration of your headaches. Browse B vitamins here – and remember that B vitamins help raise your energy levels, so you should take them in the morning.

What autoimmune diseases cause ice pick headaches? ›

One small study from 2012 found a link between autoimmune disorders, such as multiple sclerosis, lupus, and autoimmune vasculitis, with ice pick headache occurrence.

Why do I wake up with a headache everyday? ›

A number of sleep or health disorders, as well as personal habits, can trigger a headache when you wake up. Sleep apnea, migraine, and lack of sleep are common culprits. However, teeth grinding, alcohol use, and certain medications can also cause you to wake up with a headache.

What supplements help menopause? ›

Menopause Supplements: 10 Best Vitamins to Manage Symptoms
  • Magnesium. For many women in our Menopause Solutions Facebook group, magnesium (particularly magnesium glycinate) has been a game changer. ...
  • Vitamin A. Your body can get vitamin A from two forms. ...
  • Vitamins B6 and B12. ...
  • Vitamin K. ...
  • Vitamin C. ...
  • Calcium. ...
  • Vitamin D. ...
  • Omega 3s.

What vitamins help with menopause migraines? ›

Vitamin B complex

Improving your resilience to stress is also likely to have a positive impact on the frequency and duration of your headaches. And remember that B vitamins help raise your energy levels, so you should take them in the morning.

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