Not Just a Headache: Migraine Across Women’s Lifespan at WHAV 2025

New York, NY — At the 2025 Women’s Health Annual Visit (WHAV), neurologists Dr. Jelena Pavlović (Albert Einstein College of Medicine) and Dr. Amaal Starling (Mayo Clinic) delivered a comprehensive session on migraine, highlighting its disproportionate impact on women, the influence of hormones across the lifespan, and evolving treatment strategies tailored to female patients.

Migraine as a Global Health Issue with a Gender Gap

Migraine is among the most common and disabling neurologic conditions worldwide, affecting more than 1 billion people. Prevalence peaks in women during their reproductive years, with roughly one in four women aged 30 to 39 living with migraine. Compared to men, women experience more frequent and longer-lasting attacks, higher rates of associated symptoms, and greater disability. Despite this burden, diagnosis often lags behind, with many women seeking care but not receiving an accurate assessment.

Hormonal Influences Across the Lifespan

The session emphasized the strong link between migraine and hormonal fluctuations. Estrogen withdrawal, particularly in the late luteal phase, was described as a reliable trigger for menstrual migraine. Attacks typically occur in the window spanning two days before to three days after menstruation. This predictability offers opportunities for targeted “mini-prevention” strategies, such as short-term use of NSAIDs or triptans around menstruation.

During pregnancy, many women experience an improvement in migraine frequency, but perimenopause is often associated with worsening symptoms due to erratic hormonal fluctuations. Postmenopausal women, particularly those with a history of menstrual migraine, may experience relief once hormones stabilize. Importantly, induced menopause—whether surgical or medically induced—was discouraged by the presenters, since it is associated with worsening migraine and poor outcomes. 

Treatment Strategies: Acute and Preventive

Dr. Starling underscored the importance of distinguishing between acute and preventive care. Everyone with migraine requires access to effective acute therapies. Options include triptans, ditans (e.g., lasmiditan), gepants (ubrogepant, rimegepant, zavegepant), and neuromodulation devices. Gepants, in particular, offer an advantage for patients with cardiovascular risk since they lack vasoconstrictive properties.

Prevention is indicated for individuals with four or more monthly migraine days—a threshold highlighted repeatedly during the session. Preventive strategies now extend beyond traditional oral medications (such as beta-blockers, antiepileptics, and antidepressants) to include CGRP-targeting monoclonal antibodies and gepants for daily or every-other-day use. OnabotulinumtoxinA also remains an established preventive option for chronic migraine.

Special Considerations: Life Stages and Comorbidities

The speakers stressed tailoring treatment to women’s life stages:

• Pregnancy: Acetaminophen and metoclopramide are generally first-line; triptans may be used when needed, with growing evidence supporting safety.

• Lactation: Triptans and some newer gepants show low transfer into breast milk, allowing continued treatment.

• Perimenopause: Comorbid vasomotor symptoms may influence therapy choice, with some antidepressants (e.g., venlafaxine) providing dual benefits.

• Comorbidities: Women with migraine are also more likely to experience conditions such as endometriosis and irritable bowel syndrome, which can complicate management.

Non-drug approaches were also highlighted. Neuromodulation devices offer both acute and preventive benefit, though insurance coverage remains a barrier. Supplements such as magnesium, riboflavin, and coenzyme Q10 were discussed as safe and accessible options, with magnesium oxide noted to be especially helpful in perimenstrual migraine.

Reducing Disparities

The session also addressed inequities in migraine care. Only 12% of women with migraine receive effective diagnosis and treatment, despite the condition being the leading cause of days lived with disability among women aged 15 to 49. Strategies to reduce disparities include expanding telemedicine, advocating for insurance coverage of modern preventive options, and empowering non-specialists to identify and treat migraine effectively.

Key Takeaways

• Migraine affects one in four women of reproductive age and peaks in prevalence and disability during midlife.

• Hormonal fluctuations, especially estrogen withdrawal, are major triggers across the lifespan.

• All patients with migraine need effective acute treatment; prevention is recommended for those with ≥4 monthly migraine days.

• Newer therapies—including gepants, CGRP monoclonal antibodies, and neuromodulation devices—offer effective, well-tolerated options.

• Care should be tailored to life stage, comorbidities, and patient preference, with an emphasis on shared decision-making.

• Induced menopause is associated with worsening migraine.

• Addressing disparities in access to care remains an urgent priority.