Migraine in transgender people
Important information
Migraine is more common in women than men. By contrast, cluster headache, another primary headache disorder with some similar features to migraine, is more common in men than women.
During migraine attacks, women report more non-headache symptoms like nausea, vomiting, sensitivity to light or sound and attacks of longer duration than men. Migraine with aura is more common in women than men. These differences are mostly attributable to hormone changes in women, from puberty to menopause.
This section looks at specific issues and management of migraine for transgender people.
Migraine in transgender people
Most research on migraine doesn’t distinguish between sex (as a biological construct, typically categorised as male, female and intersex based on physical appearance at birth but often categorised as a male/female binary) and gender (as a social construct, reflecting cultural associations with biological sex but independent from sex). There’s very little research on migraine in non-binary and transgender individuals. Cisgender describes people whose gender identity (an individual’s internal sense or conception of their own gender) matches their sex assigned at birth; transgender describes people whose gender identity differs from their sex assigned at birth.
One small study from the Netherlands found that migraine prevalence in transgender women taking gender-affirming hormone therapy was 26%, which was similar to the prevalence in cis-gender women (25%) but much higher than in cis-gender men (7.5%). Migraine aura was also higher than expected. This strongly supports the idea that sex hormones (especially estrogen) play a significant role in the expression of migraine disease and in explaining the higher prevalence of migraine in women. It may be that puberty blockers used in people assigned to females at birth could reduce the development of migraine in these individuals.
Given that changes in estrogen are implicated in menstrual migraine in cis-gender women, it’s important to maintain steady (not fluctuating) levels of estrogen in transgender women with migraine. It may also help to establish the lowest dose of estrogen that provides acceptable feminisation. In people with migraine with aura, there’s a small increased risk of stroke with the use of estrogen.
This risk can be minimised by not smoking tobacco and managing any other stroke risk factors such as high blood pressure, diabetes and high cholesterol levels.
For transgender men, migraine attacks may still be provoked by underlying estrogen fluctuations even in the absence of periods. Depo-Provera (progesterone) injections may help in these cases. The use of testosterone may reduce the frequency and severity of migraine attacks in transgender men who have pre-existing migraine disease.
For all transgender people on gender-affirming hormone therapy, if anti-seizure medications are used for migraine preventive treatment, then hormone levels may need to be monitored and doses adjusted because of potential interactions between these treatments.
Transgender people are at higher risk of chronic conditions, including pain and mental health issues, due to stress from stigma and discrimination. For example, discrimination at the level of the individual can cause stress through interpersonal attacks and even violence.
Discrimination at the system level can cause stress through lack of access to gender-affirming healthcare. All of these factors can increase the risk of migraine and chronic migraine in transgender people. These factors can also contribute to transgender people having poorer access to appropriate migraine treatments and a higher risk of medication overuse headache.
