A chapter in the recent volume Gender and Migraine offers further details on the mechanisms behind the increased occurrence of migraine in trans women on HRT, the kinds of migraines that trans people experience, and when trans people are most likely to experience them.
Maassen van den Brink & MacGregor (2019) note that high levels of estrogen are associated with migraines that feature auras, a sensory phenomenon that can feature flashing patterns of light or blind spots, while lower levels of estrogen are associated with migraines without auras. The authors observe that trans women taking high doses of estrogen appear to experience an elevated rate of migraines with aura. They speculate that this may be because estrogen increases susceptibility to cortical spreading depression, a neurological phenomenon linked to migraine aura. Estrogen can also affect the serotonin and opioid systems as well as certain neuropeptides, which have been linked to migraine, and notably increases circulating levels of nitric oxide in trans women, which can directly cause migraines. Conversely, testosterone is likely to decrease trans men’s likelihood of migraines.
The authors recommend that transdermal estrogen, such as patches or gel, are preferable to oral estradiol in order to achieve more steady dosing. They suggest that injectable estrogen should be avoided due to the resulting high peaks (producing migraine with aura) falling to low trough levels (producing migraine without aura), but state that this can be avoided with more frequent injections or a reduction in dose. Because aura has been associated with an increased risk of ischemic stroke in trans women, and estrogen may increase the risk of embolism, the authors recommend that trans women “should be counselled about the importance of smoking cessation as well as actively managing other modifiable cardiovascular risk factors.” In trans men, even if menstrual suppression has been achieved with testosterone, ovarian suppression may not be complete, leading to estrogen withdrawal migraines; depot medroxyprogesterone acetate may effectively address this.
The benefits of HRT are something that many trans people are understandably unwilling to go without; at the same time, migraines are just a miserable and unbearable experience. As noted, modifications to one’s HRT regimen can help to make migraines less frequent, and whether you’re trans or cis, there are plenty of effective treatments available. Since my last post on this, monthly injectable CGRP inhibitors for migraine prevention have been further developed into oral CGRP inhibitors taken as needed for aborting migraine attacks. This may provide a greater safety profile than commonly used triptan drugs, which produce a constriction of blood vessels that can be dangerous in those who already have cardiovascular risk factors. The bottom line: if you’ve been having migraines since starting HRT or changing your dose, this is worth discussing with your healthcare provider to find a treatment that works for you. ■
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Thanks so much for mentioning this.
I (afab) had migraines from the time I was 11 (misdiagnosed and mistreated as 'chronic sinusitis' grrrr, despite at least 2 generations of family history) that became unmistakable - even to doctors - when I started having auras in my mid-20s. Eventual dietary changes helped bring them into remission for almost a decade, despite my initial skepticism.
When I started T last year at 39, the migraines cranked right back up (on the other side of my head!). No auras, but still crippling, and this time with major nausea, the one symptom I'd avoided in the last round.
This time, I went to a headache specialist -- something I should have done a long, LONG time ago. In 15 minutes, he prescribed real medicine that really works to *prevent* them, something I hadn't been offered/granted in 25+ years of gutting through it.
tldr: migraines are real. don't suffer. magnesium helps a lot, and rx drugs have come a long way in the last few decades, too.