Assessing and Treating Migraine in Women and Men

Differences in Seeking and Receiving Care

Migraine is heavily stigmatized, leading many individuals with the disorder, regardless of gender, to go undiagnosed or to underreport symptoms.⁵ This norm may exist, in large part, because migraine, like many chronic pain conditions, is an “invisible” disease. In addition, despite the millions of men with migraine, the disease is still thought of as a “woman’s disease” and therefore often delegitimized by the public, providers, and employers.⁴ Healthcare providers have the opportunity to drive discussion around migraine in ways that address this stigma and ask more detailed questions to identify those with suspected migraine.

Women with migraine are more likely than men to consult a healthcare provider about their symptoms, which may be because women on average have more severe and disabling attacks than men.^3,32 Men may be more hesitant to consult a healthcare provider to report symptoms because of the feminization of migraine. Women are also more likely to have received a diagnosis of migraine, tension headache, or sinus headache from a healthcare provider.^3,33 They are less likely to be diagnosed with cluster headache,³ which is more prevalent in men.³⁴ Women are also more likely than men to have sought care for their headaches in the emergency department or in urgent care.^3,33 It is important to recognize these gender differences to help overcome patient and provider bias in the diagnosis and treatment of migraine.

Differences in Treatment Response and Use

When considering treatment options for their patients, it is important for clinicians to understand the observed differences in migraine treatment use and response between women and men. Women with migraine are more likely than men to take prescription medicine (acute and prophylaxis) or a combination of prescription and over-the-counter medications to treat their attacks, while men are more likely to take over-the-counter medications or no medications at all.^3,33,35 Women are also more likely than men to use complementary and alternative medicine approaches, and in particular, acupuncture, homeopathy, massage, and yoga.36 Interestingly, use of complementary and alternative medicine is associated with decreased odds of moderate mental distress among women, but not men.³⁶ More research is needed to better understand why.

Few studies have looked at or reported sex differences in efficacy of migraine therapies. Of the studies that have, the focus has been on triptans. Some studies have found that women had higher headache recurrence rates post-triptan use,^37-39 while one large pooled analysis did not find this difference.⁴⁰

There have been no clinical trials on the use of migraine therapies during pregnancy or breastfeeding.^29,31 Some migraine therapies are contraindicated for pregnancy, although others—including acetaminophen and sumatriptan—are shown to be relatively safe.^31,41-44 Healthy lifestyles, trigger avoidance, and biobehavioral treatments are also important management tools during pregnancy and breastfeeding.^31,42

Conclusion

Since sex and gender play a crucial role in the risk, pathophysiology, and management of migraine, it is important that clinicians take differences between women and men into account when diagnosing and treating the disease. However, more research is needed to truly understand these differences and optimize care for both women and men. As noted, there are currently no sex-specific guidelines for acute treatment of migraine, aside from menstrual migraines. Researching and developing sex-specific guidelines may be an important aspect for the field to consider to improve migraine treatment for the entire adult population.