Menstrual Related Migraines. If you have women in your life or are a women yourself you probably know someone who gets migraines around their monthly cycle and maybe even you yourself experience these. For some individuals it starts with a headache and increases to sensitivity to light, feeling nauseas, dizziness and for many women that suffer with mentrual related migraines it often becomes debilitating for hours to days.

When it comes to migraines before puberty men and women get migraines at similar rates. However, after puberty women are 2-3 times more likely to suffer with migraines. For many women migraines are related to their menstrual cycle. These migraines are called menstrual related migraines, MRM. Of the individuals that get migraines up to 70% of those individuals notice their migraines getting significantly worse during the perimenstrual time period, the time leading up to menstruation. In fact individuals that suffer from MRM have migraines during this time that are more severe and debilitating and occur at higher frequency than typical migraines.

Migraines are complicated and aren't completely understood. However, there are some things that we do know about migraines and to fully understand why menstrual migraines occur it's important we talk about some of the underlying science and theories of why migraines occur.

Here we go. Essentially what we know to this point is migraines are a mix of a threshold disorder and a sensory processing disorder.

What does that mean?

Our body is constantly bringing in information from our different senses then trying to make sense of it so that we can continue to move and function in an ever changing world.

From a sensory processing standpoint it means that when the body is able to properly process different senses (what we see, what we feel, what we hear, the feeling of our body's position) coming from our eyes, inner ear, and muscles we are able to function properly and not have pain.

For instance your brain wants to keep your eyes level with the horizon. It does this by taking information from your inner ears (vestibular system), eyes, and muscles of the body to determine our position against gravity and then makes appropriate adjustments. The information coming from each of these systems to tell the brain our position should be the same. Essentially our eyes should think we are in the same spot our neck thinks we are in and our neck should be telling the brain we are in the same spot as the inner ear is telling the brain. If these systems are sending accurate information about the position of the body we are good to go. However, if one of these systems has been injured or compromised in a way where it sends inaccurate information paired with accurate information to the brain, the brain then has to process that information and make a decision on what is or isn't accurate. (see image on the bottom right)

From a threshold disorder standpoint it means that normally everything in the body is working and the body is able to supply the proper amount of resources to the right areas, nerves are able to conduct properly and we don't have migraines. However, if different stressors in the body cumulate or there is an injury or injuries in the body the brain then has to respond by allocating resources to different areas not allowing full function of the other processes in the body, this is called a brain-compensatory mechanism (What happens when we are slightly dehydrated). Normally this happens on a small level and we don't notice any pain or changes. However, our body can only adapt to so much before we start feeling a negative effect due to the cumulation of stress and inability of all the processes to work together. Essentially the body has a threshold for how much stress a system can take before it reaches a threshold where the body starts to experience pain. In the case of mesntrual related migraines when this threshold is met it results in migraines.

So what about menstrual related migraines?

More science first.

The brain controls nearly every function in our body. It does this by transmitting information throughout the body through nerves. This information is transmitted through impulses meaning that say when you touch something it causes an electrical spike. This electrical spike is called an action potential and our brain interprets that electrical signal as touch. Depending on the type of nerve, the sensors or receptors attached to the nerve, and where the nerve is gong to or coming from the brain is going to interpret these signals in different ways.

So say I lightly touch something. My brain gets the signal from nerves that I am lightly touching something. As I push harder the nerves continue to signal to the brain and the brain realizes by the signals that something is pressing on the finger harder.

Now let's say that I am pushing on a piece of foam. As I push further into the foam the foam gets firmer and I can feel it get firmer because the rate of these electrical signals is increasing and the brain interprets that as pushing harder. Now let's say I am pushing this foam and through this foam on the other end is a nail or something sharp. When I eventually hit the nail with my finger my brain is going to prioritize the sharp sensation as being dangerous and we pull away.

Essentially you have an information highway going from your finger to your brain and its telling you what you are feeling. However, this highway can only carry so much information and sometimes information is going to get to the brain and the brain is going to ignore it because it deems other information (electrical impulses) as higher priority, exactly like the scenario above.

Now have you ever stubbed your toe or touched something sharp and you end up rubbing the area that you pricked or stubbed? Well that's because when we do that it sends different nerve signals at a higher rate to the brain and essentially drowns out the pain signals that were being sent from either stubbing our toe or pricking our finger.

The main takeaway is that the brain gets electrical impulses from nerves and what we feel is determined by the electrical impulses sent from these nerves. To take it one layer deeper at the end of these nerves are different receptors or sensors. For instance there are receptors that are focused on soft touch like the scenario above pushing on the foam and there are receptors on these nerves that are focused on sharp touch and pain, these are the ones that didn't send signals until the finger pushed into the sharp object and then those signals were prioritized by the brain and we felt the sharp pain more than the pressure. Then by pulling the finger away from the sharp object and rubbing on our finger we activated the soft touch sensors which drowned out the sharp signals and caused the sensation of the sharp pain to go away.

Now let's start tying in why nerve signals are a key part of menstrual related migraines.

To do that we need to talk a little bit more about nerves. There are 12 pairs of nerves that come directly off our brain and they are called the cranial nerves. This is a view looking up from the bottom of the brain and you can see all the cranial nerves are listed. While I would love to dive into each one of the nerves the one we want to focus our attention on today is the trigeminal nerve. It's the big blue bundle that has three big parts coming off of it.

The trigeminal nerve is a very complex nerve because it sends and receives a lot of information and has many connections to other parts of the body.

The trigeminal nerve feels sensation of our face through three different branches. The opthalmic (touch scalp), maxillary (touch maxilla) and mandibular (touch mandible). The trigeminal nerve also controls our chewing muscles, a little muscle in our ear called the tensor tympani, and then a group of 3 muscles that are involved in biting, chewing and swallowing.

The trigeminal nerve also controls blood flow in parts our brain. Which leads us back to talking about migraines.

The trigeminal nerve specifically controls the blood vessels that supply oxygen and nutrition to the protective layers of tissue around our brain. These tissues are called meninges and consist of the Pia, Arachnoid, and Dura Mater. While most of the brain doesn't feel and can't perceive pain these meninges can feel pain and the blood vessels that supply these meninges have the sensors and receptors that feel pain as well.

When the trigeminal nerve and other components that interact with the vascular system of the meninges are injured or brought to an abnormal state (above the threshold for migraines to occur) we feel migraine type pain. When this occurs it also has the potential to alter the blood flow to the pain sensitive meninges and pain sensitive arteries and veins of the head further increasing the migrainous pain.

So how does menstrual related migraines play a role in this and why do a select group of women experience more intense painful migraines during menstruation?

For the most part the brain doesn't feel. If I were to magically be able to go through the skull and prick the brain you wouldn't feel anything. You might lose some function or abilities but you wouldn't feel anything because the majority of the brain doesn't have the receptors that allow us to feel pain.

However, there are areas in the brain that do have those receptors and consequently allow us to feel pain.

The specific pain receptors that we are talking about are pain receptors that come from, you guessed it, the trigeminal nerve that we talked about above.

These pain receptors, which come from the trigeminal nerve, are located on blood vessels that supply oxygen and nutrition to three protective layers around the brain, meninges, which are called the Dura, Pia, and Arachnoid mater. You can see these layers on the picture on the right.

Since these structures are throughout the entire brain and are pain sensitive structures, when these structures are aggravated or the blood vessels that go to these structures are aggravated we start to get the symptoms of a migraine. Now here is the thing about migraines. They aren't completely understood and there are 100s of different ways these blood vessels and layers can get irritated (many of the ways have to do with that trigeminal nerve which we talked about earlier) and when they get irritated they cause migraines in many individuals but in others that doesn't always happen. Also since these pain sensitive structures send the information about pain through branches of nerves coming off the trigeminal nerve if those nerves are negatively affected it can cause someone to have symptoms of a migraine while the structures that are "causing the pain" are actually fine and have no directly measurable reason to be causing us pain.

Now that we have some of our bases covered and hopefully a little bit of an understanding on what causes migraines let's dive into the why behind Menstrual Related migraines.

1st Hypothesis - Estrogen Withdrawal Theory

Almost 50 years ago scientist started trying to figure out why some women experienced more intense migraines during their cycle and why certain women would only get migraines during menstruation. To try and figure this out they looked at the different hormone levels that change throughout the menstrual cycle.

What they found is that there was a correlation with the decrease of estrogen during the late luteal phase of the menstrual cycle and migraines.

This led to the "Estrogen Withdrawal Hypothesis". Essentially what they initially thought caused MRMs was the decrease in estrogen after a phase of high amounts of estrogen. Look to the picture on the right and you can see a red box noting the time when estrogen decreases right before menstrual related migraines occur.

They looked to confirm their findings by treating individuals with MRMs by giving them a steroid that mimicked the function of estrogen. What they found was that this helped reduce the rate of migraines.

From this time more studies have been done that have repeatedly shown that a decrease in estrogen increases the possibility of experiencing a MRM. It is thought that the decrease in estrogen makes the trigeminal nerves more excitable lowering the threshold for migraines to occur. However, we also know that high levels of estrogen also make the trigeminal nerves more excitable and also lower the threshold for migraines to occur.

So both high levels of estrogen and low levels of estrogen have the potential to cause the trigeminal nerve to be more excitable and decrease the threshold for migraines to occur. Since both high and low levels of estrogen cause the same response it means that while estrogen is involved in menstrual related migraines its not clear to what extent. The leading thought currently when it comes to estrogen and migraines is that rather than high or low levels of estrogen leading to migraines, it might actually be the rapid change of estrogen levels that contributes to migraines.

As you can see on the picture to the right though estrogen doesn't just rapidly decrease once during the menstrual cycle it also decreases rapidly in the middle of the menstrual cycle and that's not when menstrual related migraines occur. So again while estrogen is a component of menstrual related migraines in doesn't paint the full picture.

As you can see in the picture estrogen isn't the only factor that is fluctuating throughout the menstrual cycle. The green line represents magnesium and magnesium not only plays a key role in the menstrual cycle but also in migraines.

In fact one thing we know about magnesium is that it is an independent risk factor for migraines. Meaning if you have low magnesium you are more likely to have migraines. When magnesium levels drop below normal levels it increases the chance of a migraine episode by 35 fold. It is important to note that magnesium plays an important role in keeping nerves healthy and functioning properly (this plays a role that we will talk about later) and there has been promising research done showing that supplementing with magnesium decreases the frequency of menstrual related migraines.

So far we think estrogen plays a crucial role in menstrual related migraines and we know magnesium plays a role in migraines when magnesium levels are below normal levels.

Now on to oxytocin. Oxytocin is a hormone produced in the brain, specifically an area called the hypothalamus. Oxytocin is known to play a big role in humans specifically when it comes to sex, childbirth, social bonding, milk production, fear, and behavior. It's obviously a very important and a very complicated hormone that plays a distinct role in many different scenarios. When it comes to menstrual related migraines though it's the final piece that helps to explain why menstrual migraines occur.

Remember earlier where we talked about menstrual related migraines as a threshold disorder and the role the trigeminal nerve plays? Here it is if you don't.

The trigeminal nerve specifically controls the blood vessels that supply oxygen and nutrition to the protective layers of tissue around our brain. These tissues are called meninges and consist of the Pia, Arachnoid, and Dura Mater. While most of the brain doesn't feel and can't perceive pain these meninges can feel pain and the blood vessels that supply these meninges have the sensors and receptors that feel pain as well.
When the trigeminal nerve and other components that interact with the vascular system of the meninges are injured or brought to an abnormal state (above the threshold for migraines to occur) we feel migraine type pain. When this occurs it also has the potential to alter the blood flow to the pain sensitive meninges and pain sensitive arteries and veins of the head further increasing the migrainous pain.

So what role does oxytocin play in migraines? Well oxytocin helps to decrease pain and the transmission of pain signals to the trigeminal nerve. This decreases the amount of pain we perceive and also raises the threshold for migraines to occur. Essentially meaning that oxytocin acts as a kind of buffer for pain. Meaning when oxytocin is high we would need more pain and more dysfunction of the trigeminal nerve and associated structures in order for a migraine to occur.

And what happens with oxytocin during the menstrual cycle?

Well as you can see on the picture on the right oxytocin is highest during ovulation and then starts dropping to its lowest right before menses occurs, coinciding with the onset of menstrual related migraines.

Magnesium, oxytocin, and estrogen are all near their lowest points right before menstrual related migraines occur. Essentially this puts the threshold for a migraine to occur the lowest it will be all month.

If there is damage or irritation of the trigeminal nerve or associated structures and the threshold for a migraine to occur for this individual has not yet been met an individual might be migraine free all month but will experience a migraine once the threshold drops right before menses occurs.

A Scenario.

Let's say a woman was in a car accident and hit her head, she didn't have a concussion and overall pretty fine after the accident. However, she did have some stiffness in the back of her neck. What she didn't realize, and how could she, is that during the accident she strained a small muscle in her neck called the rectus capitis posterior. This small muscle has a direct connection with the pain sensitive dura mater that sends pain signals to the brain via the trigeminal nerve. The injury to the muscle and dura occurred and signals were sent to the trigeminal nerve that typically would have resulted in a migraine. However, this individual was in the middle of their cycle meaning that there were high levels of estrogen and high oxytocin meaning that their migraine threshold was higher and it was not met during this time and consequently a migraine didn’t occur.

However, as the month continued the injury to that muscle and dura remained and as the oxytocin levels dropped and magnesium levels dropped the threshold for migraine was lowered, the pain signals going from the dura remained and a migraine occurred.

Now in this example above a specific event happened that led to an increase in firing of the pain sensitive structures and then when the individual got closer to menses their threshold for migraine lowered and this resulted in a menstrual related migraine. However, the example above is just that, an example. Many women suffer from menstrual related migraines and they don't have a specific event of accident that occurred before they started experiencing menstrual related migraines. For many women their first migraine occurs shortly after their first period and there isn't a specific event besides the change in hormones that occurs.

Menstrual Related Migraines occur due the combination of dropping levels of magnesium, oxytocin, and estrogen. This decreases the threshold for migraines to occur, increasing the likelihood of a migraine.

Where do we go from here?

Migraine pain has to come from somewhere and for many individuals it is due to one or a combination of; an inability to process the different senses, inflammation of the pain sensitive structures connected to the trigeminal nerve, and/or a lower threshold for migraine to occur caused by low magnesium and a combination of dropping hormones before menses.

If magnesium levels are below normal levels it increases the chance of a migraine occurring and guess what? 50% of the United States is deficient in magnesium according to the American Osteopathic Association. If you suffer from migraines I'd suggest talking to your primary care physician about having your magnesium levels checked and possibly starting a regiment of supplementing with magnesium or at least increasing the amount of magnesium rich foods in your diet.

Oxytocin is complicated. We know that there are natural ways to increase oxytocin levels but no studies have been done to show that naturally trying to increase oxytocin levels improve migraines symptoms. We know that women who are pregnant have higher levels of oxytocin and also lower occurrences of migraines. We also know that women who breastfeed versus bottle feed have higher levels of oxytocin due to the feed forward mechanism of oxytocin release during breast feeding and consequently have less frequent migraines. Currently research is being done on intranasal oxytocin spray to help reduce migraines and so far it is showing promise at being effective but large scale studies still need to be done.

I hope you found this blog informative and helpful and if you have any questions as always feels free to reach out via email at drcoffman@optimizecolumbus.com.

References

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Menstrual Related Migraines

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