Pain in the membrane. Pain in the brain. Oestrogen’s role in headaches.

This A.I generated image conjures the sense of pressure that I feel when in the throws of a migraine. It misses the black spiders swimming through my vision (scintillating scotomata). It doesn’t reflect the way that my right side goes numb with my tongue feeling too big in my mouth and my right fingers going cold (pararesthesiae). It doesn’t reflect the way that I cannot form sentences, cannot find words (hemisensory loss with aphasia). This is my experience of aura. When it passes I know that there will be intense pain. Though unpleasant it is almost a blessing, at least I am back in my body again.

I am one of millions of people who experience menstrual-related headaches. These are tied to changing oestrogen levels in my cycle. Oestrogen is linked to serotonin and glutamate function. Serotonin helps the communication between nerve cells and is involved in the pain sensing process. Glutamate is an excitatory neurotransmitter that sensitises nerves and releases peptides. During the low oestrogen phase of the menstrual cycle (pre menstrual and the first three days of bleeding) the production of serotonin decreases, leading to the increased release of calcitonin gene-related peptide (CGRP) and substance P from the trigeminal nerve. These substances are the key agents for general migraines. They cause vasodilation of blood vessels and sensitisation of the trigeminal nerve. Here is a picture of the three branches of the trigeminal nerve. These nerves carry pain, temperature and touch information from the skin of the face; mucosa of of the sinuses. nose and mouth; the teeth and portion of dura.

The resulting inflammatory changes to our meninges leads to the permeability of the blood-brain barrier increasing. These are our beautiful meninges - three layers of membranes that cover and protect your brain and spinal cord.

To top it all off, our pain perception (nociception) is more intense around menstruation due to a decrease in our self-made-opioid activity. It seems very unfair to know that during our period, we are more likely to feel pain and feel it more intensely. Luckily there are things that we can do to prevent our headaches and/or make them less intense. In an ideal world we would all have proper sleep, eat really well, have routine meal schedules, regular exercise, and we would manage our stress levels. This is always the first approach to migraine prevention. These lifestyle changes are unrealistic for many of us, so let’s assume that we are all doing our best and let’s look at what else we can do.

The first is to know your migraine patterns. There are some great headache tracking apps out there. These images are from Head App. I have taken to using it since entering the wonderful world where “new or markedly increased migraine headaches” is a diagnostic criteria of peri-menopause. Head App records the date and duration of each headache, the intensity and location, and whether it responded to therapy. Additionally, potential triggers such as food, alcohol, stressors, weather conditions, and menstrual timing can be logged.

I was interested to read in my course notes that supplements with vitamin B2 or riboflavin (400mg); magnesium (400-600mg); feverfew 50-82mg; and co-enzyme Q10, have been found to reduce migraine incidence and severity. I have ordered a combined ginger, B2 and feverfew supplement and will see for myself if it helps at all. B2 normalises the production of serotonin and improves the function of an enzyme called methylenetetetrahydrofolate reductase which is linked to migraines. Magnesium shelters neurons from glutamate. It also reduces inflammation, stabilises serotonin receptors and inhibits the release of substance P. Q10 helps convert nutrients such as fatty acids and carbohydrates into energy-producing adenosine triphosphate, which helps fuel energy transfer within cells. Feverfew is said to stop prostaglandins from dilating the blood vessels.

Stacy Sims advocates hydration and nutrition to mitigate the changes in blood pressure and sudden dilation and constriction of blood vessels that come with headaches and migraines. She recommends staying hydrated to keep the circulation healthy. She also recommends eating food rich in nitrates. Nitrates convert to nitric oxide which widens blood vessels and hopefully reduces the severity of the headache. Some nitrate rich foods are beetroot, pomegranate, watermelon and spinach.

Cold application is another approach that is gaining interest. Some advocate a minute long cold shower every day to prevent migraines. Research is exploring cold cap therapy during an episode with promising results.

A conventional medical approach would be to take a non steroidal anti inflammatory at the first sign of a headache. NSAIDs block a specific enzyme called cyclooxygenase (or COX) used by the body to make prostaglandins. Prostaglandins are hormone-like chemicals in the body that contribute to inflammation pain and fever by raising temperature and dilating blood vessels.

If the headache turns into a migraine you might take a triptan (I take frovatriptan). All triptans are serotonin 1b/1d receptor agonists. They prevent pain by blocking trigeminal nerve activation, they inhibit the release of vasoactive peptides, and they promote vasoconstriction.

Some women use hormone therapy to manage their migraines. I have not yet explored this avenue as I know that drugs containing oestrogen should be avoided in patients with auras. It may be that I use the lower dose transdermal oestrogen during the dropping oestrogen window. Perhaps a doctor will recommend that I take progesterone at night during the luteal phase or try progesterone cream. For now, I will take my vitamins, avoid my triggers and try to live as low-stress and well-slept a lifestyle as I can.

I’d love to know what you do to manage your migraines.

And here is a bonus class on the skull for you 💀

xx

P