Are Migraines Different in Women and Men?
Migraine headache (MHA) is a common neurologic disorder with prevalence greater among women than men in a 3:1 ratio. The difference is usually explained as being related to hormonal differences between the sexes. However, given that a significant number of men develop MHA, this explanation seems insufficient to fully explain the disproportionate ratio.
A new study that assessed the differences in experience of MHA between women and men also looked at MHA in women who were perimenstrual and nonperimenstrual. Click through the slides below for highlights of the findings.
A new prospective study using electronic headache diaries (E-diary) sought to determine whether there are differences between the sexes in how they experience MHA. To try to better understand the role hormonal differences may play in MHA, women in the study were divided between perimenstrual (considered as the 5-day period starting 2 days before menstruation and lasting until day 3) and nonperimenstrual MHA.
Perimenstrual MHA episodes lasted the longest followed by nonperimenstrual MHA. MHA episodes were shortest in men. Perimenstrual MHA but not nonperimenstrual MHA in women were more severe than MHA in men.
In both perimenstrual and nonperimenstrual women, MHA were more likely to be accompanied by photophobia, phonophobia, and nausea than those in men with MHA. Men were more likely to experience MHA with aura than either group of women. Women and men both had similar response rates to triptan medications.
There appear to be differences between MHA in men and women and in women, less pronounced differences between perimenstrual and nonperimenstrual MHA. Among women, hormonal changes play a role in severity of MHA and how long they last.
It is unclear why women in the study were more likely to experience photophobia, phonophobia, and nausea while men were more likely to experience aura. This is of significance as many headache specialists believe that MHA with aura may be a different syndrome with a different etiology than MHA without aura.
Study authors presented several potential theories to explain the difference in MHA symptoms based on previous studies:
- CGRP, which has been implicated in MHA, may be responsible for photophobia and phonophobia and its release may be increased in women with MHA.
- Altered dopamine levels in the hypothalamus has been suggested as a cause of the nausea seen in MHA but whether sex-relateddifferences are involved is uncertain.
- Sudden drops in estrogen levels may be associated with MHA without aura in women, which could explain the greater prevalence of aura in men with MHA.
The authors also speculate as to whether the observed differences in symptoms and pain severity may, at least to some degree, reflect psychosocial and cultural factors that may have affected what men and women self-reported in their diaries. They note, however, that although other studies on pain have noted possible gender differences in how pain conditions are reported, there is little absolute evidence to support this with regard to MHA.
This study highlights how the complex nature of MHA may result in different experiences between men and women as well as how MHA may be different in women depending on whether they are perimenopausal or non-perimenopausal.
Unfortunately, in studies on treatments for MHA, there is often little differentiation between those with aura and those without, much less any focus on whether men and women respond differently to various therapies. Separating out the various subgroups might enable clinicians to target what is most likely to work for the individual patient.
Reference: Verhagen IE, van der Arend BWH, van Casteren DS, et al. Sex differences in migraine attack characteristics: A longitudinal E-diary study. Headache. 2023;63:333-341.
