If you’ve been unlucky enough to experience a migraine before, chances are, you are a woman. Migraines are three times more likely to affect women than men after puberty. And among those who do get migraines, they affect women more severely too, especially migraines that are hormonally triggered by rising and falling estrogen and progesterone levels, which appear most commonly during puberty, menstruation, and menopause.

Yes, menstrual migraines are a thing, and if you have a variety of painful premenstrual symptoms, you might be experiencing one and mistaking it for regular PMS.

Let's start with the delightful basics: migraines are not just headaches. They encompass a slew of debilitating pre- and post-headache symptoms, which can include nausea and light sensitivity or—when it comes to aura migraines—temporary partial loss of vision and slurred speech. They can make you irritable, cause strange food cravings, make the side of your body tingle, and make a dark, quiet room your only sanctuary.

What sets a menstrual migraine apart from other kinds? First of all, timing. Because menstrual migraines are triggered by a change in hormones, the time to look out for them is in the days leading up to your period, says migraine expert Dr. Susan Hutchinson, advisor to the migraine relief ear plug brand MigraineX. Next, Hutchinson looks at specific symptoms and how debilitating they are to differentiate between PMS and a full-blown menstrual migraine. She'll ask patients whether their head pain is throbbing, if they’ve avoided normal activities like exercise due to pain, and if there’s any degree of nausea or sensitivity to light. When the answer to all three is yes, those PMS symptoms are likely signs of a hormonal migraine.

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There's no cure for reoccurring migraines, and what sets them off varies from person to person, so doctors work with patients to treat symptoms with a combination of pain medications and preventative measures. The key to that balancing act is figuring out what your trigger is because a menstrual migraine, triggered by hormone changes, will respond differently than a migraine triggered by a change in barometric pressure, stress, or allergens.

"The only way a person's going to know [their triggers] is by being their own detective,” says Hutchinson. "Look back when you get a migraine, maybe 24 to 48 hours leading up to it, and think: Was there a change in weather? Did you have Chinese food [often containing migraine-triggering MSG]? And as a woman, is it just before my period? It's a collaborative effort with my patients to find out these triggers, but they're the ones keeping a diary of all these things.”

Identifying what provokes migraines for you is step one in finding the best course of treatment. Common triggers include stress and rapid drops in barometric pressure, a.k.a the weather. "Migraine sufferers have inherited a very sensitive nervous system, so changes externally in the environment or internally in their own body often trigger a cascade of migraines,” Hutchinson explains. The drop in pressure affects your inner ear and sinuses, which is why some migraine sufferers say they can tell when a storm is coming even before the weatherman can. Once you determine the most likely trigger, confirmed by your healthcare provider, you can tailor your pain management approach. For example, MigraineX earplugs reduce the intensity and duration of weather-related migraines by slowing the shift of atmospheric pressure dips.

When it comes to menstrual migraines, one possible source of relief is birth control. Hormonally triggered migraines essentially kick women while they’re down, hitting hardest when levels of estrogen and progesterone fluctuate. Hormonal birth control alters your hormone levels, which—depending on the type—can either exacerbate or prevent migraines. If Hutchinson's menstrual migraine patients want contraceptives, she tends to prescribe them a low-dose birth control (meaning she tells patients to skip the placebo week, if taking pills) to try and keep estrogen and progesterone levels stable. For patients who don't need contraception, she suggests using an estrogen patch during menstruation.

But, she says, "You have to be careful because, in a small percentage of women, hormones may aggravate their headache instead of help because the hormones in birth control pills are synthetic; they're not bio identical. Estradiol (estrogen patches) are great for those women because they're bioidentical, meaning it has the same makeup as a woman's ovaries."

For women who experience ocular migraines—migraines that involve visual disturbances, also known aura migraines—though, taking the pill can be dangerous. "If the woman has migraine with aura and we put her on the birth control pill, there could be a slight increased risk of stroke," Hutchinson warns, urging women who experience aura migraines to share that information their their birth control-prescribing doctors. "I want to watch those women carefully."

She also suggests triptans like prescription Imatrex or over-the-counter acetaminophens like Excedrin Migraine. Supplements like Magnesium (400-500 milligrams a day) may help too, she says, because many people who suffer from migraines have lower levels of Magnesium in their bodies. Taking a steady dose of the supplement may help reduce migraine frequency or even prevent menstrual migraines altogether.

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