16.1 Headache Disorders in Women: Migraine, Tension-Type, Red Flags & Hormonal Considerations
Key Takeaways
Migraine is about three times more common in women; migraine with aura makes estrogen-containing contraception US MEC Category 4 because of ischemic stroke risk.
Triptans treat moderate to severe migraine but are contraindicated in coronary or cerebrovascular disease and uncontrolled hypertension; gepants and lasmiditan are alternatives.
Preventive therapy is considered with 4 or more headache days per month; topiramate and valproate are teratogens, and topiramate above 200 mg/day can lower contraceptive hormone levels.
Medication-overuse headache develops with simple analgesics on 15 or more days per month or triptans on 10 or more days per month.
A new or changed headache in pregnancy or postpartum, a thunderclap onset, neurologic signs, papilledema, or new headache after 50 needs urgent evaluation (SNOOP4 red flags).
Primary Headache Types
| Feature | Migraine Without Aura | Migraine With Aura | Tension-Type | Cluster |
|---|---|---|---|---|
| Typical patient | Women about 3:1; peaks ages 25–55 | Same | Most common headache overall | More common in men, but women are affected |
| Duration | 4–72 hours | Aura of 5–60 minutes, then headache | 30 minutes to 7 days | 15–180 minutes, often daily in clusters |
| Character | Unilateral, pulsating, moderate to severe, worse with activity | Same, preceded by fully reversible visual, sensory, or speech symptoms | Bilateral, pressing or band-like, mild to moderate | Severe unilateral orbital pain |
| Associated | Nausea or vomiting, or photophobia and phonophobia | Same | No nausea; at most one of photophobia or phonophobia | Tearing, rhinorrhea, ptosis, and restlessness on the same side |
Migraine diagnosis (ICHD-3) requires at least 5 attacks meeting these features. Aura most often shows as a zigzag scintillating scotoma spreading over minutes.
Why Aura Matters in Women's Health
Migraine with aura roughly doubles ischemic stroke risk, and estrogen adds to it. Combined hormonal contraception is US MEC Category 4 for migraine with aura at any age (Category 2 for migraine without aura under 35, and 3 at 35 or older). Progestin-only methods and IUDs are Category 1–2. Always ask about aura before prescribing estrogen.
Acute Migraine Treatment
- Mild to moderate attacks: NSAIDs (ibuprofen, naproxen), aspirin, or acetaminophen-aspirin-caffeine, taken early.
- Moderate to severe attacks: Triptans (sumatriptan, rizatriptan, others), alone or combined with an NSAID. Triptans are contraindicated in coronary artery disease, stroke or TIA, peripheral vascular disease, uncontrolled hypertension, and hemiplegic or brainstem aura; typical migraine with aura is not a contraindication.
- When triptans are contraindicated or fail: Gepants (ubrogepant, rimegepant), which do not constrict vessels, or lasmiditan (causes driving impairment for 8 hours).
- Nausea: Metoclopramide or prochlorperazine, which also relieve headache.
- Avoid opioids and butalbital compounds, which worsen outcomes and lead to overuse.
Medication-Overuse Headache
Using simple analgesics on 15 or more days per month or triptans, combination analgesics, or opioids on 10 or more days per month for more than 3 months can cause daily headache. Treat by withdrawing the overused drug and starting prevention.
Preventive Therapy
Consider prevention with 4 or more headache days per month, disabling attacks, or failure of acute treatment.
| Drug | Notes for Women |
|---|---|
| Propranolol or metoprolol | First-line; propranolol is acceptable in pregnancy when needed (monitor fetal growth) |
| Amitriptyline | Helps coexisting insomnia or tension-type headache |
| Venlafaxine, candesartan | Alternatives (avoid candesartan in pregnancy) |
| Topiramate | Effective but teratogenic (oral clefts); doses above 200 mg/day lower contraceptive hormone levels; cognitive side effects |
| Valproate | Avoid in people who could become pregnant (neural tube defects, lower child IQ) |
| CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab, eptinezumab) and atogepant or rimegepant | Effective and well tolerated; limited pregnancy data, so stop several months before conception |
| OnabotulinumtoxinA | For chronic migraine (15 or more headache days per month) |
Menstrual Migraine
Attacks occur from 2 days before through 3 days after the start of menses, triggered by estrogen withdrawal. Options include frovatriptan or naratriptan "mini-prophylaxis" during that window, scheduled NSAIDs, or extended or continuous combined hormonal contraception to remove the hormone-free interval (only if there is no aura).
Other Headache Disorders
- Tension-type headache: Treat with NSAIDs or acetaminophen, stress management, and physical therapy; use amitriptyline for frequent episodes.
- Cluster headache: Abort attacks with 100% oxygen at high flow or subcutaneous sumatriptan; prevent with verapamil (ECG monitoring).
- Idiopathic intracranial hypertension: Typically young women with obesity; daily headache, pulsatile tinnitus, transient visual obscurations, and papilledema, with a risk of permanent vision loss. Confirm with imaging and lumbar puncture (high opening pressure); treat with weight loss and acetazolamide. Tetracyclines, excess vitamin A, and isotretinoin are triggers.
Red Flags: SNOOP4
| Letter | Red Flag | Possible Cause |
|---|---|---|
| S | Systemic symptoms (fever, weight loss) or secondary risk (cancer, HIV, immunosuppression) | Infection, metastasis |
| N | Neurologic signs or confusion | Stroke, mass, infection |
| O | Onset sudden ("thunderclap"), maximal within a minute | Subarachnoid hemorrhage, reversible cerebral vasoconstriction |
| O | Older age at onset (over 50) | Giant cell arteritis (check ESR and CRP), mass |
| P | Pattern change, progressive headache, positional headache, precipitated by Valsalva, papilledema, or pregnancy and postpartum | Mass, intracranial pressure changes, cerebral venous thrombosis, preeclampsia |
Headache in Pregnancy and Lactation
- Migraine, especially without aura, often improves in the second and third trimesters and may recur postpartum.
- Acute treatment: Acetaminophen first, with metoclopramide; sumatriptan is reasonable when needed (pregnancy registry data are reassuring). Avoid NSAIDs after about 20 weeks, and avoid ergotamine and dihydroergotamine, which are contraindicated.
- Prevention: Propranolol or amitriptyline if needed; avoid topiramate and valproate.
- A new or different headache after 20 weeks or postpartum must be evaluated for preeclampsia, as well as cerebral venous thrombosis, reversible cerebral vasoconstriction syndrome, posterior reversible encephalopathy syndrome, and post-dural puncture headache (see the puerperal complications section).
- Lactation: Ibuprofen, acetaminophen, and sumatriptan are compatible with breastfeeding.
A 24-year-old with migraines asks for a combined oral contraceptive. She describes 20 minutes of a shimmering zigzag line in her vision that spreads across her visual field before each headache. Her blood pressure is normal, and she does not smoke. Which contraceptive recommendation is correct?
A combined pill is acceptable (Category 2) because she is younger than 35 and does not smoke.
A combined vaginal ring is preferred because it bypasses first-pass liver metabolism.
Combined methods are Category 4 because of migraine with aura; offer a progestin-only method or IUD.
No contraception is needed because frequent migraine attacks reduce fertility.
A 38-year-old has 10 headache days per month and takes an over-the-counter acetaminophen-aspirin-caffeine product on most of them. Her headaches have become daily. Which diagnosis is most likely contributing?
Idiopathic intracranial hypertension
Subarachnoid hemorrhage
Cluster headache
Medication-overuse headache
A 31-year-old at 33 weeks of gestation with a history of migraine without aura presents with a new, severe, persistent headache unlike her usual migraines, with spots in her vision. Which step is most important before treating it as migraine?
Give sumatriptan and send her home if the headache improves within 2 hours.
Check blood pressure and evaluate for preeclampsia with urine protein and lab studies.
Prescribe ibuprofen 600 mg around the clock for 3 days and recheck by phone.
Start topiramate for migraine prevention and refer her to neurology after delivery.
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