Migraine headaches, trans people, and hormone therapy

From age 3 or 4, which is as far back as I can remember, I experienced chronic, frequent migraine headaches, just as my mother and her father have had throughout their lives. These episodes of severe pain would often happen once or twice a week, accompanied by intense nausea, with my parents often having to pick me up from school. I was typically given Tylenol or Motrin for this, but nothing really seemed to be effective against the pain, and I would generally have to spend a day sleeping it off. These attacks became somewhat less frequent after age 9, and I only had about one every week or two after that. From age 12-13 I was given daily cyproheptadine as a preventative medication due to how much school I was missing, with Excedrin Migraine (aspirin, Tylenol, caffeine) as needed. However, once I began to experience many of the most rapid and prominent physical changes of puberty during ages 14 to 15, the frequency of migraine attacks dropped sharply: for the rest of my teenage years, I would only have migraines once or twice a year.

This would change once I started feminizing hormone therapy at age 23, and I soon began to experience attacks at least once or twice a month. Just as the surge of testosterone at puberty was accompanied by a reduction in migraines, the chemical suppression of testosterone and introduction of estrogen seemed to herald their return. I could no longer take aspirin or any NSAIDs due to my Crohn’s disease, but I’ve since gotten a prescription for Imitrex taken as needed, a triptan drug that works well for getting rid of a migraine within a few hours. I’ve also become more experienced in noting various signs that suggest the leadup or aura of a migraine, such as mood changes and sensory hypersensitivity.

Sex hormone levels have long been noted to influence the occurrence of migraines in cis people: those assigned female experience migraines much more commonly than those assigned male, whose migraines often tend toward remission after childhood (Jamieson, 2017). Similarly, those assigned male who have higher levels of estrogen and lower levels of androgens are more likely to experience these headaches (van Oosterhout et al., 2018). Estrogen levels have also been linked to migraines during menstruation (Chai et al., 2014), and oral contraceptives can increase the occurrence of migraines (Edlow & Bartz, 2010).

The effect of sex hormones on migraine frequency and severity can be a concern for trans people when considering whether to start cross-sex hormone therapy for physical feminization or masculinization. Pringsheim & Gooren (2004) observed that in a large cohort of trans women taking HRT, there was a significantly higher prevalence of migraines compared to cisgender men, and a prevalence similar to that seen in cisgender women. Conversely, there’s been a case report of one trans man whose migraine headaches improved with HRT (Penzien, 2008).

Medical sources such as the Center of Excellence for Transgender Health at UCSF warn that both feminizing HRT and masculinizing HRT can potentially cause an increase in migraines, and consent forms for hormone therapy have often mentioned that estrogen and testosterone may worsen migraine headaches in certain individuals. Additionally, given the frequent history of migraines seen in those with depersonalization disorder (Cahill & Murphy, 2004), trans people with depersonalization may want to be especially vigilant.

Migraine headaches, while painful and debilitating, are a very treatable condition. There are many medical options, and new medications, such as the long-acting CGRP antagonists, are continuing to come to market. Every individual is different, and many trans people may not experience migraines at all, or may not see any changes in their migraines after starting HRT. But for those who do have these severe symptoms, there are many possibilities for effectively keeping migraines under control when transitioning. ■