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14 Articles in Volume 19, Issue #1
Analgesics of the Future: NKTR-181
Antidote to CDC Guideline; Plantar Fasciitis; Patient Input
Assessing and Treating Migraine in Women and Men
Demystifying Opioid-Induced Hyperalgesia
Editorial: Have We Gone Too Far? Can We Get Back?
How to Compel Patients to Complete Home Exercises
Inflammation Targeted Nanomedicine
Intravenous Stem Cell Administration for Ileitis
Invasive Surgery: Effective in Relieving Chronic Pain?
Pain Catastrophizing: What Practitioners Need to Know
Pain Therapy Options for the Home
Regenerative Medicine
The Future of Pain Management: An Experts' Roundtable
Whole Body Vibration: Potential Benefits in the Management of Pain and Physical Function

Assessing and Treating Migraine in Women and Men

A look at the differences in risk, presentation, and care.
Pages 45-47
Page 1 of 2

As a stigmatized, painful disease that disproportionately affects women, migraine has significant negative consequences for individuals, their families, and society as a whole. Migraine is three times more common in women, reaching peak prevalence between 30 and 39 years of age, at a time when many women are rapidly growing in their career and balancing work, family, and social obligations. As a result, women account for a large majority of the estimated $78 billion in migraine-associated economic costs in the United States,1 representing about 80% of both direct medical costs and lost labor costs.2

Migraine affects women differently than men both physiologically and socially. The biological differences between women and men, as well as sociocultural norms, are key variables in the etiology, diagnosis, and management of migraine. In addition, because of the high preponderance in women, the disease has become feminized, furthering the differences between women and men in seeking and receiving care.3-5

The Society for Women’s Health Research recently published a report6 that assesses the state of the science of sex differences in migraine and calls for more research on, and attention to, these differences in order to improve care for both women and men. It is important to apply what we know to both scientific research and clinical practice, including migraine detection, treatment, care, and education. As such, this article provides a review of what is known about sex differences in migraine and its relevance to clinical care.

Pain is reported more frequently by women than men, and specific pain conditions, such as migraine, are considerably more common in women than in men. (Source: 123RF)

Differences in Risk Factors

Determining the differences between women and men in migraine risk factors, such as those outlined below, may aid clinicians in diagnosis and management, leading toward a more personalized care approach.

Female sex hormones are thought to be a major risk factor in migraine, which may explain, in part, the differences in prevalence and presentation between women and men. Changes in migraine prevalence in women correlate with periods of large hormonal shifts (eg, puberty, pregnancy, menopause).7 One longitudinal study found that earlier age of a woman's first menstrual cycle increased risk for migraine.8

Sociocultural factors may play a role in the observed differences in migraine between women in men as well. For example, victims of intimate partner violence and adverse childhood experiences are associated with an increased risk for migraine, and rates of sexual harassment and assault are higher in women.9-11

Some studies show being female itself is a risk factor for transformed migraine (ie, the transition from episodic to chronic migraine)12,13 although results on this are mixed.14 The risk factors for both women and men for transformed migraine include depression, anxiety, and headache-related nausea, all of which are more commonly reported in women than men.15-17 These data suggest that women with episodic migraine could be at a higher risk for transitioning to chronic migraine than men.

Differences in Presentation

Migraine may present differently in women and men, and understanding the differences for each subtype and their associated comorbidities may help clinicians improve diagnosis and treatment. Women are more likely to experience longer and more intense migraine attacks, report more migraine-associated symptoms – including nausea, visual aura, blurred vision, photophobia, and phonophobia – and have higher levels of migraine-related disability (eg, requiring bed rest with attacks, reduced productivity at school or work).3,18 On the other hand, men experience less headache-related disability and are more likely to report being able to work/function normally during a migraine attack.3

Comorbidities are very common in migraine patients, with nearly 90% of all individuals with chronic migraine having at least one comorbid condition.19 On average, women with migraine have 11 comorbid conditions, while men have five.18 The types of comorbid conditions can differ between women and men as well. Some evidence suggests women with migraine are more likely to have anxiety, depression, fibromyalgia, endometriosis, and restless legs syndrome, whereas men with migraine are more likely to have obesity, coronary thrombosis, diabetes, epilepsy, and kidney stones, although other data show conflicting results.3,20-22

As noted, hormonal fluctuations are a common trigger for many women with migraine,23 with up to 50% of women with migraine experiencing attacks that co-occur with menstruation.24,25 Menstrual migraine, which is defined as migraine attacks occurring in at least two of three menstrual cycles, extending from two days prior to onset of menses through three days after onset, is a female-specific migraine subtype.26 Menstrual migraine attacks can be more disabling (leading to a larger loss of productivity), more severe and longer lasting, and more resistant to treatment than non-menstrual migraine.27,28

There are also extra barriers to receiving a menstrual migraine diagnosis, including the need for diary documentation for at least three menstrual cycles and the fact the menstrual migraine does not appear in the main text of the International Classification of Headache Disorders (ICHD), but is only found in the appendix.26 The lack of codification implies that menstrual migraine has been deemed less important in the healthcare community and further enhances the general lack of awareness about this migraine subtype, which places a disproportionate burden on women with the disease. In addition, treatment strategies for menstrual migraine may differ from those for non-menstrual migraine. For example, treatment options for menstrual migraine tend to include mini prophylaxis or estrogen supplementation around the time of the menstrual period.29-31

Last updated on: April 12, 2019
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Sex and Gender Differences In the Pain Experience
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