This is a website dedicated to extrapelvic endometriosis. So why are nosebleeds and headaches part of the conversation? The incidence of both nosebleeds and headaches at time of menstruation is a common occurrence. In online support groups these questions are frequently asked and discussed. In fact, often these discussions include concerns about the possibility of endometriosis lesions in nasal or brain tissue. This is a perfect place to discuss these concerns with inclusion of cases with endometriosis in the respective areas.
What is a Migraine? Are they all the same?
Not another headache. No, for real. Did you know there are many types of headaches? According to the National Headache Foundation there are at least (23) different types of non-migraine headaches. The American Migraine Foundation has classified (5) different forms of Migraine (not including Menstrual Migraine). Persons assigned female sex at birth suffer from headaches more often than men. Migraines occur three times more often in women (26%) compared to men (8%). (Migraine and tension-type headache in a general population: precipitating factors, female hormones, sleep pattern and relation to lifestyle. Rasmussesn BK. Pain 53: 65-72.) and 2000 (Prevalence of Migraine in Taipei, Taiwan: a population-based survey. Wang SJ et al. Cephalgia 20:566-572).
- Why do persons assigned female sex at birth get more headaches?
- Do hormone cycles contribute to headaches?
- If I have endometriosis, am I more likely to have headaches or Migraines?
- Is it true endometriosis can occur in the brain?
The purpose of this short article is to familiarize you with the most common headaches among persons assigned female at birth and those associated with hormones and endometriosis.
Let’s start by understanding the difference between non-Migraine (regular headaches) and Migraine headaches:
A Migraine is considered a neurological disease. It presents with temporary, unusual sensory and/or motor experience(s) (what we ‘feel’ through our body from the environment or our ability to do something: speak and move). These unusual sensations or difficulty to move can occur before the headache starts. This is a Migraine with Aura. If the abnormal experiences only occur during the headache it is a Migraine without Aura. A few examples of abnormal experiences include: seeing black dots, unusual smells, tingling, numbness, weakness in part of body and having trouble speaking). If an Aura is present, it usually lasts 10-30 minutes. Migraines with and without an Aura usually include: light or sound sensitivity (photophobia, hyperacusis), nausea and vomiting. Migraines occur on one-side of the head and pulse or throb. The American Migraine Foundation, has identified (5) types of Migraines:
Migraine with Aura – A period of altered sensory/motor experience lasting up to 30 minutes followed by a headache on one-side, accompanied by nausea, vomiting and often light or sound sensitivity.
Migraine without Aura – One sided headache (pulsing, throbbing) with nausea, vomiting and often light or sound sensitivity.
Migraine w/o head pain – An usual form. An aura is usually experienced with nausea but there is NO headache. ‘Silent Migraine’ ‘Acephalic Migraine’ (without the head).
Hemiplegic Migraine – One side of the body tingles or feels number and/or weak in addition to the headache on one-side.
Retinal Migraine – In addition to the one-sided headache, there is a loss of sight in one eye. The blindness may last minutes to months but there is usually full recovery of eyesight.
Chronic Migraine – Presence of a ‘Migraine’ > 15 days/month but the intensity can vary through its duration.
Are hormone and Migraine headaches ever the same thing? Yes. The fluctuations in hormones at time of menstruation and ovulation can cause Migraines. Approximately 60% of persons assigned female sex at birth who suffer from Migraines report they occur during these times. (American Migraine Foundation).
Are these headaches the result of estrogen or progesterone levels fluctuating? To answer simply, Yes. There is a classification know as ‘Menstrual Migraine’. A Menstrual Migraine may or may not have an ‘aura’ before it.
To re-ask the question: are hormonal and migraine headaches ever the same thing? Sometimes they differ. A Menstrual Syndrome Headache (PMS) does not include altered sensory or motor experiences despite the associated decline in hormone levels that coincide. These headaches (PMS Headaches) usually involve both sides of the head along with fatigue, constipation and skin changes.
Can persons assigned female sex at birth have either a non-Migraine or Migraine associated headache at the time of menstruation and ovulation? Yes. Both types of headaches are induced by hormonal changes.
Before discussion of endometriosis and migraines, we highlight hormone therapies.
Are headaches associated w/ hormone use? Endometriosis? or Both?
Hormones are used to treat numerous conditions. Auxiliary estrogen helps control symptoms of menopause in women. Oral contraceptives (OCP’s) are used for reproductive health conditions and prevent conception. These hormone therapies may create or amplify Migraine headaches. (Postmenopausal hormone therapy and migraine headache. J Womens Health. Misakian AL et al. 2003. 12: 1027-1035) (Oral contraceptives and increased headache prevalence: the Head-HUNT study. Aegidius K et al. 2006. Neurology 66: 349-353).
Just as estrogen is associated with increased Migraines, persons assigned female sex at birth who suffer Migraines reported a drop in the frequency of their headaches while they were receiving progesterone-only hormone treatments. (An evidence-based approach to hormonal contraception and headaches. Harris M and Kaneshiro B Contraception. 2009. 80:417-421). Persons assigned female sex at birth treated with a male hormone reported the intensity of their Migraine symptoms were better controlled during their hormone treatments (Efficacy of danazol in the control of hormonal migraine. Lichten EM et al. J Reprod Med. 1991. 36:419-424).
Many persons with endometriosis receive hormone interventions as treatment to manage symptoms of the disease. Knowing this, it is easy to conclude that the association of Migraines among persons assigned female sex at birth with endometriosis is associated to their use of hormones (estrogen-based hormones) for symptom management of the disease, which then increases frequency and intensity of their Migraines. However, multiple studies have concluded that, when hormone use was factored out, persons with endometriosis had a 1.7 x increased risk of Migraine headaches compared to those without endometriosis.
The current belief is that Migraine and endometriosis are co-morbid conditions (they are found together among a person but one does NOT cause the other one to occur). This is the same relationship as Adenomyosis and endometriosis. Migraines and endometriosis have a common ‘denominator’; they are both influenced by estrogen. (Women with endometriosis are more likely to suffer from migraines: a population-based study. Meng-Han Y et al. Plos ONE. 2012;7(3): 1-5).
In the study by Meng-Han et al. of 985 women with endometriosis, 79% reported their Migraine diagnosis came after their endometriosis diagnosis. The authors presume that the endometriosis lesions create a hypersensitized nervous system due to formation and activation of sensory fibers within the lesions or chain of complex inflammatory processes that increases sensitivity of the brain.
Two significant findings that lead to the idea of co-morbid conditions:
1) Migraines and endometriosis are more common in persons assigned female sex at birth who start menarche at a younger age. Migraines appear earlier in the same adolescents who have endometriosis. (Endometriosis and Headache. Stovner LJ et al. Current Pain Headache Rep. 2011. 15:415-419). The presence of Migraines has been identified as a ‘screening tool’ for adolescents who may have endometriosis. (Jerri Miller, Presenter: The Prevalence of Migraines in Adolescents with Endometriosis. World Congress Endometriosis 2017. Vancouver, BC, Canada)
2.) There is evidence that persons who suffer from these conditions have genetic predisposing factors that play a role in both disorders. In fact, the genetic factors identified play a specific role in estrogen receptor function. This information helps bring the topic ‘full circle’ (Common Genetic Influences Underlie Comorbidity of Migraine and Endometriosis. Nyholt DR et al. Genet Epidemiol. 2009;33(2):105-113) (Endometriosis and Headache. Stovner LJ et al. Current Pain Headache Rep. 2011. 15:415-419).
As you can see, the situation is very complicated. Although our sex hormones are only produced in very small quantities, they are very powerful compounds with an impact on many systems in our body, not just reproduction. Now that awareness of how common headaches, Migraines particular, are among persons with endometriosis, we can briefly discuss endometriosis located directly in the brain.
Brain endo? Does it really occur? How ‘common’ is it?
Does endometriosis occur in the brain? Yes. It has been documented. But, only a handful of cases have been published. Database search for publications in English revealed isolated cases of brain (cerebrum), tissues covering the brain and spinal cord (meninges) and areas below the brain (brainstem and cerebellum) have been reported. All but one case (Case 1) require fee to access each full article. Hence, only a brief summary based upon case abstracts for those are given.
Case 1: A 40 yr old woman without a history of endometriosis and delivered a healthy baby 3 years before, experienced a progressive decline in balance and ability to walk. She had no prior cyclic headaches or seizures. Imaging confirmed a mass in the Cerebellum (organ below the brain). Surgical findings: solid mass with multiple cystic compartments. She recovered well. It is unclear if any regrowth has occurred. (Cerebellar Endometriosis. Sarma D. et al. AJR.2004;1543-1546)
Case 2: (abstract only) Woman with a 3 year history of headaches and generalized seizures (no details provided). CT images detected a lesion in the right parietal lobe of the brain. Surgical removal of lesion confirmed endometriosis. (Cerebral endometriosis: case report. Thibodeau LL et al. J Neurosurgery.1987;66:609-610)
Case 3: (abstract only) Woman with history of repetitive partial seizures on the first day of her menstrual cycle. She underwent surgery for lesion removal. (A case of cerebral endometriosis causing catamenial epilepsy. Ichida M et al. Neurology. 1993;43:2708-2709)
Case 4: (abstract only) This case reports a woman with long history of headaches associated with her menstrual cycles (catamenial but no details provided). The abstract states she had episodes of unconsciousness. Eye examination revealed swelling behind her eyes with these episodes. Information available in the abstract does not state how conclusion of recurrent subarachnoid hemorrhage(s) was diagnosed. Based upon its ‘catamenial’ time frames (around menstruation) and result of estrogen suppression stopped further hemorrhages it is implied that endometriosis was the original cause . (Recurrent subarachnoid hemorrhage due to endometriosis. Duke R, Fawcett P, Booth J. Neurology.1995;45:1000-1002)
Case 5: (abstract only). A woman with history of heavy menstrual bleeding and neurological signs and symptoms (catamenial time frame but no details provided). CT and MRI imaging showed a lesion deep in the left side of the brain. The woman was treated medically with gonadotropin-releasing hormone agonist for 3 months then surgical removal of both ovaries. Based on the abstract it is unclear if the patient refused or was not a candidate for surgery due to lesion location in the brain. No details are given about patient age or her past medical history. (Resolution of Catamenial Epilepsy after Goserelin Therapy and Oophorectomy: Case Report of Presumed Cerebral Endometriosis. Vilos GA et al. JMIG.2011;18(1):128-130).
Summary:
It’s a bit complex: Headaches, hormones and endometriosis. It is apparent that a lot of persons assigned female sex at birth suffer from headaches, one type or another. Here we highlighted the effect of hormones that precipitate PMS Headaches and Menstruation Migraines. We identified Migraines and endometriosis as comorbid conditions that have been suggested to have common genetic link(s). We also recognize that endometriosis can occur in the brain but are very isolated cases. With the understanding that Migraines often present with altered sensation and sometimes difficulty with movement or speech and increased occurrence in those with endometriosis, a Neurologist as part of your care team is very important to monitor your condition.
There is an interesting relationship between sufferers of epilepsy and the catamenial period (around menses). But that is a separate topic from endometriosis.
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