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PMDD and Migraine: Which Hormonal Treatments Are Safe? · The Sirona Health Podcast: PMDD, Hormones & Mental Health

• 0:04
  Hormones don't just run your cycle.
• 0:07
  They run your mood, your mind, your whole sense of self.
• 0:11
  I'm Dr.
• 0:12
  Georgina Standen, GP and founder of Sirona Health, and this is the Sirona Health Podcast, where we talk about the relationship between female hormones and mental health properly without the mystique and without the dismissal.
• 0:27
  Back in the episode on the combined pill, I said that migraine with aura rules out one of the most effective treatments we have for PMDD, and that I'd give the topic its own episode.
• 0:38
  This is that episode.
• 0:41
  Migraine matters in this series for a few reasons: it's common in women, it's strongly linked to hormones, and it changes which hormonal treatments are on the table.
• 0:52
  If you have PMDD and migraine, or you suspect you might have both, the order in which you ask the questions makes a big difference.
• 1:00
  First, is this migraine, and does it come with aura?
• 1:06
  Second, what does that mean for your options?
• 1:09
  That's where we're going today.
• 1:11
  Let's start by sorting out what kind of headache we're talking about, because headache covers a lot of ground.
• 1:18
  The commonest type is tension type headache, which tends to be a dull, band-like pressure and doesn't usually stop you functioning.
• 1:27
  Migraine is different.
• 1:29
  It comes in attacks, usually lasting between four and 72 hours, and it tends to get in the way of what you're doing.
• 1:37
  There's a very quick screening test clinicians use.
• 1:40
  It's three questions: Does light bother you when you have a headache?
• 1:45
  Does the headache impair your ability to function?
• 1:48
  And do you feel nauseated or are you sick?
• 1:52
  If you answer yes to at least two of the three, migraine is likely.
• 1:58
  Cluster headache is a third type.
• 2:00
  It's much rarer and very different.
• 2:03
  Severe, one-sided pain around the eye in bouts and treated quite differently.
• 2:09
  I'm not going to cover it here, but if that sounds like it's you, it's worth seeing your own GP One safety note before we go on.
• 2:17
  Most headaches are not dangerous, but a few features need prompt medical attention.
• 2:24
  A headache that comes on suddenly and reaches its peak within minutes, any new weakness, double vision, or loss of balance, a change in personality or consciousness, or a headache after a head injury, those need assessing urgently rather than waiting for a routine appointment.
• 2:44
  Before we go further, I need to explain what aura is because it matters so much for the hormonal options.
• 2:51
  About a third of people with migraine get aura.
• 2:55
  It's a temporary neurological disturbance that comes before the headache or sometimes alongside it.
• 3:02
  Over 90% of auras are visual, zigzag lines, shimmering, blind spots.
• 3:09
  Some are sensory, like pins and needles spreading across the face or hand, and a smaller number affect speech or language.
• 3:18
  What marks out a true aura is the pattern.
• 3:22
  The symptoms build gradually over at least five minutes, last somewhere between five minutes and an hour, and then they completely clear, usually before or as the headache starts.
• 3:35
  They typically persist if you close your eyes, which is a useful clue for visual aura.
• 3:41
  That's different from the vague warning signs some people get hours before an attack, like feeling tired or having blurry vision that sticks around through the headache.
• 3:52
  Those aren't aura.
• 3:54
  I keep coming back to this distinction because it has a big consequence.
• 3:58
  The presence or absence of aura largely decides whether we can use estrogen-containing treatments, and it's easy to get this wrong in either direction.
• 4:09
  Some women are told they have aura when they don't and miss out on a treatment that might have helped.
• 4:16
  Others have aura and don't realize it.
• 4:19
  If there's any doubt, it's worth getting it assessed carefully, and sometimes that means a neurology opinion.
• 4:26
  There's also a flag worth knowing about.
• 4:29
  If aura looks unusual with weakness on one side, double vision, symptoms in one eye only, poor balance, or reduced consciousness, that isn't typical migraine aura, and it needs investigating.
• 4:44
  And if you're taking a combined pill and develop aura for the first time, tell your doctor, because a switch is likely to be recommended.
• 4:53
  Now, let's look at how migraine connects with your cycle.
• 4:57
  Menstrual migraine is migraine that's linked to your period.
• 5:02
  The usual definition is attacks that happen from about two days before your period to the first three days of it in at least two out of three cycles.
• 5:13
  There are two versions.
• 5:15
  Pure menstrual migraine means you only get attacks around your period.
• 5:21
  Menstrually related migraine means you get attacks around your period, but also at other times in the month.
• 5:28
  The second is far more common.
• 5:31
  Pure menstrual migraine is rare, thought to affect fewer than one in 100 women with migraine.
• 5:39
  How many women have some link between their migraine and their periods depends on how you ask.
• 5:45
  Estimates run from roughly one in five women with migraine, up to as many as a half or two-thirds noticing a connection.
• 5:53
  Part of the reason for the range is that it's easy to overlook the link, and it may not become obvious until the late 30s or 40s.
• 6:03
  Why does it happen?
• 6:04
  The main trigger appears to be the fall in estrogen just before a period.
• 6:10
  Prostaglandins, the chemicals that peak around menstruation and cause period pain, probably contribute, too.
• 6:18
  Notice that your hormone levels are typically normal.
• 6:21
  As with PMDD, the issue is thought to be sensitivity to normal hormonal change, not abnormal levels.
• 6:28
  Menstrual attacks also tend to be different.
• 6:32
  They're often longer, more severe, and more likely to come back the next day and harder to treat than attacks at other times.
• 6:41
  They are also more often without aura, even in women who have aura at other times in the month.
• 6:49
  The way to confirm it is a diary.
• 6:52
  Record your headaches, your period days, and any medication you take for at least two to three cycles.
• 7:00
  That's the most accurate method, and there's no blood test or scan for it.
• 7:05
  So how does migraine fit with everything we've covered on PMDD?
• 7:10
  The similarities are striking.
• 7:12
  In both, the symptoms are tied to the cycle.
• 7:16
  The hormone levels are normal, and what seems to matter is how sensitive the brain is to the changes.
• 7:23
  In migraine, the estrogen drop is a recognized trigger.
• 7:28
  In PMDD, we've talked about progesterone, allopregnanolone, and estrogen drop.
• 7:35
  There is some early evidence that they overlap.
• 7:39
  A recent study of about six hundred women with migraine in Egypt found that those with menstrual migraine reported more severe premenstrual symptoms than those with migraine at other times.
• 7:52
  PMDD was also diagnosed more often in menstrual migraine group, about six percent compared to two percent, although that different wasn't large enough to be statistically significant, and the number of women with PMDD was small.
• 8:09
  The study also couldn't show which came first, so I treat it as a pointer rather than proof.
• 8:16
  I think it's reasonable to wonder whether the two reflect a shared hormonal sensitivity, and many women have both.
• 8:24
  But I'd call that a possibility rather than an established fact.
• 8:29
  The authors suggest a mechanism involving falling estrogen and serotonin, but that hasn't been tested clinically, and I'm connecting the dots here.
• 8:39
  One practical point from the authors that I agree with is that if you have menstrual migraine, it's worth being asked about premenstrual mood symptoms too, and the other way around Where the link is established is in the practical decisions.
• 8:54
  Both conditions respond badly to sharp hormonal swings, and the treatments we use for one can help or hinder the other.
• 9:02
  That includes a pill-free break, which can trigger a migraine and can bring PMDD symptoms back, and the choice of hormonal treatment, which depends on whether you have aura.
• 9:15
  One practical tip.
• 9:17
  If you track your PMDD symptoms with a daily diary, add your headaches to it.
• 9:22
  That way, you can see whether they follow the same pattern, which can change what we recommend.
• 9:29
  The question most women want answered is which hormonal options are actually safe if you have migraine.
• 9:35
  So let me take it step by step.
• 9:38
  First, migraine without aura.
• 9:41
  Here, combined hormonal contraception is generally an option.
• 9:45
  The key point is how you take it.
• 9:48
  The week without hormones causes an estrogen drop, which can trigger migraine just as it can bring back PMDD symptoms.
• 9:57
  So the usual advice is to take it continuously, running packets back to back, or at least to shorten the break.
• 10:06
  That's the same approach I describe for PMDD, which is helpful because the two conditions point in the same direction.
• 10:14
  The British Menopause Society says healthy women with migraine without aura can use continuous combined hormonal contraception containing ethinylestradiol up to the age of 50.
• 10:27
  It also notes that pills containing the natural type estrogens, estradiol in Zoely and estetrol in Drevelis, appear to have a safer clotting profile than ethinylestradiol.
• 10:40
  But that isn't yet reflected in the official product information, so I'd treat it as promising rather than settled.
• 10:48
  Second, migraine with aura.
• 10:51
  Here, the advice changes.
• 10:53
  NICE says not to routinely offer combined hormonal contraception to women with migraine with aura because of an increased risk of stroke.
• 11:03
  This is one of the clearest lines in the whole area.
• 11:06
  It applies to the pill, the patch, and the ring.
• 11:09
  So what's left?
• 11:10
  The BMS suggests the drospirenone only pill, which is Slind, which we covered earlier in the series, with or without transdermal estradiol, which is an off-license use.
• 11:21
  Estradiol given through the skin as a patch or gel isn't contraindicated by aura in the way that estrogen in a combined pill is, and it gives steadier levels than oral estrogen As I discussed in a previous episode, the use of transdermal estradiol with a progestin is also recommended treatment for PMDD So there is some potential overlap again here There are other progesterone-only options, but they're less predictable, and with PMDD, we have to choose carefully.
• 11:56
  The desogestrel pill taken every day without a break stops periods in many women, and that can help with migraine.
• 12:03
  Other progesterone-only pills are unlikely to help migraine.
• 12:07
  The Depo injection is another option, although bleeding can carry on for several months.
• 12:12
  For PMDD, remember what we covered earlier in the series, some women are sensitive to progestogens themselves, so these are worth trying carefully and tracking in your diary rather than assuming they'll be safe for you.
• 12:26
  The hormonal coil, the Mirena, is a different case.
• 12:30
  It's very good for heavy or painful periods, but it doesn't reliably stop your natural cycle, so your estrogen still rises and falls.
• 12:39
  That means it's unlikely to help migraine that's triggered by estrogen withdrawal, and for the same reason, I wouldn't expect it to treat PMDD on its own.
• 12:49
  Fourth, GnRH treatments.
• 12:51
  We covered these in the GnRH episode with add-back hormones.
• 12:55
  In principle, stable, non-cyclical hormone levels fit with the migraine principle too, but this is a specialist area, and the National Migraine Center notes that these treatments are generally reserved for specialists.
• 13:09
  So far, we've talked about hormonal options.
• 13:12
  Now let's turn to treating the migraine attacks themselves.
• 13:16
  For an acute attack, NICE recommends an oral triptan combined with an anti-inflammatory such as ibuprofen or naproxen, or with paracetamol, and an anti-sickness medicine can help even if you don't feel sick.
• 13:30
  The earlier you take it, the better it works.
• 13:33
  Avoid opiates like codeine, which aren't recommended.
• 13:38
  For menstrual migraine specifically, if standard treatment isn't enough, NICE suggests a longer-acting triptan, frovatriptan or zolmitriptan, taken regularly on the days you expect an attack.
• 13:51
  That only works if your periods are regular and predictable.
• 13:55
  If attacks happen throughout the month or short-term measures don't work, continuous preventative treatment is an option One warning I'd like to give clearly, using painkillers or triptans on many days a month, usually 10 or more, can cause medication overuse headache, where the treatment itself keeps the headaches going.
• 14:19
  The days you use for menstrual migraine count towards that total.
• 14:23
  If you're reaching for acute medication often, speak to your GP.
• 14:29
  The next question is whether migraine gets worse in perimenopause, and the answer is often yes.
• 14:35
  As periods become irregular and estrogen swings become larger, migraine frequently worsens, then tends to improve after periods stop and hormone levels settle.
• 14:47
  That isn't true for everyone, but it's the typical pattern.
• 14:52
  Hormone treatment needs thinking through here.
• 14:55
  The BMS points out that during early perimenopause, estrogen levels can be higher on average and spike unpredictably.
• 15:03
  So it suggests considering continuous combined hormonal contraception to suppress the natural cycle, which also gives contraception and helps with bleeding and menopausal symptoms.
• 15:14
  That applies to healthy women with migraine without aura up to the age of 50.
• 15:20
  For women with aura or other reasons they can't take ethinylestradiol, or for women over 50, the option is the drospirenone-only pill with or without transdermal estradiol until around 55.
• 15:35
  There's a subtle point worth knowing.
• 15:37
  Standard HRT doesn't switch off the ovaries, so in perimenopause it can add to the swings rather than smooth them.
• 15:46
  That's why cycle suppression may be more appropriate than HRT alone in that early phase.
• 15:53
  Later, in late perimenopause and after the menopause, continuous HRT can be used to manage the hot flushes in women with migraine.
• 16:02
  Transdermal estradiol, so a patch, gel, or spray, is preferred because the levels are steadier.
• 16:09
  Migraine with aura doesn't rule out HRT.
• 16:13
  The aim is the lowest dose that controls your symptoms, since higher doses can be linked to more headaches.
• 16:20
  And if you can't or don't want to take hormones, the BMS notes that escitalopram or venlafaxine can help both migraine and hot flushes.
• 16:30
  I mentioned SSRIs and SNRIs in the antidepressant episode, so it's an interesting overlap.
• 16:38
  One more thing, women who continue HRT after menopause may be less likely to see the natural decline in migraine that many women notice in the years afterwards.
• 16:49
  It's not a reason to avoid HRT, but it's worth knowing.
• 16:54
  So to bring today together, start with the question of whether it's migraine and whether it comes with aura, because that decides the most.
• 17:04
  A diary that includes your headaches and your period days is the best tool we have.
• 17:10
  If you have migraine without aura, continuous combined contraception can be a good option for both migraine and PMDD, with the key being to avoid the hormone-free break.
• 17:22
  If you have aura, estrogen-containing contraception is generally off the table, but there are still real options, including drospirenone-only pills and transdermal estradiol.
• 17:35
  Perimenopause often makes migraines worse before it gets better, and the plan changes with it.
• 17:41
  If you have PMDD and migraine, it's well worth saying both when you see a clinician, so the treatment can be chosen with both in mind.
• 17:51
  Next time, I want to look at an area where a lot of these decisions get harder, adolescence, what PMDD looks like in teenagers, who can treat it, and why it's so often missed.
• 18:03
  That's it for today.
• 18:05
  I'm Georgina.
• 18:06
  Thanks for listening.
• 18:07
  A quick note before you go.
• 18:09
  This podcast is for general information, not individual medical advice.
• 18:13
  It doesn't replace seeing your own GP or a specialist.
• 18:17
  So if anything you've heard today feels relevant to you, please do talk to someone.
• 18:22
  And if you're struggling, please reach out to your GP, to someone you trust, or to a crisis line if you need one right now.
• 18:30
  You can find Sirona Health and book your appointment at sironahealth.co.uk.
• 18:35
  See you next time