A headache that starts two days before your period and lifts once you are properly bleeding is not a coincidence. It tracks the rapid drop in your oestrogen at the end of your cycle. Dutch public health data put lifetime migraine prevalence at roughly 33% of women against 13.3% of men.
That gap is not there at birth. It opens at puberty, exactly when the cycle starts.
What strikes me about this topic: nearly every woman who has it has already worked out the pattern herself. She just does not know whether it comes from somewhere, or whether she is imagining things. I can take that second worry away. The pattern is measurable, and it has been found in large Dutch cohorts.
Below is what happens per cycle phase, when your risk peaks, how to tell ordinary headache from migraine, and which blood values add anything at all.
Why do you get a headache before your period?
The usual explanation is oestrogen withdrawal. Your oestrogen peaks in the second half of your cycle and falls away quickly in the days before your period. That fall appears to be the trigger, rather than the low value itself. The sharper the drop, the higher the chance of an attack.
Oestrogen does more in your brain than run your cycle. Among other things it influences your serotonin system and the way pain signals are processed. When it drops fast, that processing shifts with it.
Even so, this is less firmly established than most articles suggest. A 2023 critical review in The Journal of Headache and Pain went back through the evidence for the oestrogen withdrawal hypothesis and concluded that it is limited: small study groups, inconsistent definitions and varied measurement methods (PMID 37730536).
That does not make the explanation wrong. It makes it provisional.
I mention it anyway, because you will meet this account everywhere as settled fact. You deserve to know which part is solid and which part is not.
Take two women with the same 28 day cycle. In one, oestradiol falls away over two days; in the other, the same drop plays out over five. They end on the same value. In diary studies it is mostly the first who reports an attack.
When in your cycle is the risk highest?
Around your period. In a Dutch cohort of 563 women with migraine, covering 2,627 cycles, the chance of an attack was by far the highest in the perimenstrual window. The follicular phase that follows came second. Just after ovulation, no increase was found.
That last result surprised the researchers themselves. Oestrogen also falls after ovulation, and the expectation was that attacks would rise with it. They did not (Cephalalgia, 2026).
| Phase of your cycle | What your oestrogen does | Measured chance of a migraine attack |
|---|---|---|
| Luteal phase, after ovulation | Peaks, then falls gradually | Reference value |
| Perimenstrual, 2 days before to 3 days in | Sharp drop | Over one and a half times as high (OR 1.67) |
| Follicular, after your period | Low, starting to rise again | About a third higher (OR 1.31) |
| Directly after ovulation | Brief dip after the mid cycle peak | No increase found (OR 0.95) |
This table is the reason I wanted to write this piece. Almost every Dutch article on cycle headache treats ovulation and menstruation as two equally risky moments. In the measured data they are not.
What that means in practice: if your headache reliably lands mid cycle, the hormonal explanation is weaker than you would think. Something else may be going on. I work that through in headache around ovulation.
Is it ordinary headache or migraine?
That distinction matters more than it sounds. Dutch GP guidance describes a migraine attack as severe, often throbbing pain on one side of the head, lasting half a day to three days and usually accompanied by nausea. Tension headache feels more like a band around your head and lets you function.
With migraine you want to lie down, in the dark, without sound. With tension headache you carry on, reluctantly.
Some women see shimmering, flashes of light or wave like images shortly before an attack. That is called aura, and clinically it is an important distinction. It weighs into the discussion around hormonal contraception, further down this page.
One misconception I meet often: that menstrual migraine is something that happens to women without aura. It is not. In a Dutch diary study of 526 women, menstrual migraine occurred about equally often in both groups, 59% in women without aura and 53% in women with aura (PMID 37259230).
What does stand out: the attacks that arrive around menstruation usually run without aura in both groups. So you can know aura from your other attacks and have none of it around your period.
That is why you note aura per attack, not per person.
Around menstruation the attacks also tend to be heavier. They last longer, come with nausea more often, and respond less well to the usual acute treatment than attacks at other points in the cycle.
The precise criteria, and why it matters whether your attacks come only around your period or outside it as well, are in recognising menstrual migraine.
Does hormonal headache change as you get older?
Yes, and often considerably. While your cycle is regular, your pattern is usually predictable. Once the hormone swings turn irregular, in perimenopause, your headache follows. Pregnancy and menopause both change the picture, but in opposite directions.
In the American Migraine Prevalence and Prevention Study, covering 3,664 women, 8.0% of premenopausal women had ten or more headache days a month. In perimenopause that was 12.2% (PMID 26797693). Adjusted for other factors, a raised risk remained.
After natural menopause it settles down again for a proportion of women, once the swings have burnt out. What to expect in which phase is in migraine during menopause.
One more line from that same guidance, which you rarely read anywhere else: there is no evidence that hormonal treatment helps women with more migraine attacks around menopause. That is a sober statement in a corner of the internet where a great deal gets promised.
During pregnancy it usually goes the other way: oestrogen stays high and stable for months, and that stability appears to help. The per trimester figures are in migraine in pregnancy.
One point appears on virtually no Dutch consumer site, and I do want to raise it here. Dutch headache guidance records that doctors pay particular attention to combined pill use in women who have migraine with aura, because of a raised risk of stroke. That risk climbs further alongside smoking.
Do you use hormonal contraception and see shimmering or flashes before your attacks? Put it to your GP once. Not to alarm you, but because it weighs into the choice. What contraception does to your hormones more broadly is in contraception and your hormones.
Which blood values say anything about recurring headache?
None of them show migraine. That test does not exist, and any provider suggesting otherwise is selling you something the lab cannot deliver. What blood testing can do is check whether something else is playing along that mimics headache or makes it worse.
That sounds like a limitation. In practice it is exactly what your GP needs.
The values that come up most often in this context:
- Ferritin and Hb. Iron deficiency is common in menstruating women and has been linked to headache in research. A normal Hb does not rule out low ferritin.
- TSH and free T4. An underactive thyroid can cause fatigue and headache that you would easily put down to your cycle.
- Oestradiol, FSH and progesterone. These say nothing about the headache itself, but they do give context about where you are in your cycle or in the menopause transition.
The iron angle is the most worthwhile, and also the most often missed. In NHANES data covering 7,880 adults, the association between iron status and severe headache existed only in women, not in men (PMID 34295917). I work that through in headache from iron deficiency.
An example of how that goes wrong. A woman of 34 with heavy periods has an Hb of 7.6 mmol/l, comfortably inside the reference range. Her ferritin is 11 micrograms/l, which is low. The first number reassures, the second does not.
Combinations like that are exactly why the search sometimes continues past that first value.
If you want that side looked at, an iron status test gives a view of your ferritin and saturation. If you sit more on the cycle or menopause side, hormones for women fits better. Which hormone test makes sense when, and why your cycle day counts, is in hormone testing in women.
What do you take to your GP?
A pattern, not a feeling. The difference between "I often get headaches" and "my headache starts two days before my period, three cycles running, and lasts until day two" decides how the appointment goes. The second is a lead. The first is a complaint.
So keep it for three full cycles. Three, because after two you still cannot tell whether it is chance.
Note these four things per headache day:
- The cycle day, counted from the first day of your period.
- How long the headache lasted, in hours or half days.
- Whether nausea, light sensitivity or sound sensitivity came with it.
- Whether you saw shimmering or other visual symptoms beforehand.
That fourth line is the most important one, and also the one most often skipped. Aura changes the discussion around hormonal contraception, and you are the only person who can observe it.
Contact your GP promptly for headache that reaches full force within seconds, headache with fever and a stiff neck, neurological symptoms that do not resolve, or a headache pattern that starts for the first time after fifty. Those four do not belong to the cycle story.
For everything else: start with those three cycles. If you find your headache sits tight against your period, you will have explained in five minutes what otherwise takes three appointments.
References
- Raffaelli B, Do TP, Chaudhry BA, Ashina M, Amin FM, Ashina H. Menstrual migraine is caused by estrogen withdrawal: revisiting the evidence. J Headache Pain. 2023;24(1):131. PMID 37730536.
- van der Arend BWH, Bakker S, van Casteren DS, et al. Migraine attack incidence in relation to the post-ovulatory estrogen decline: a prospective cohort study. Cephalalgia. 2026. doi:10.1177/03331024261436415.
- Verhagen IE, van der Arend BWH, van Casteren DS, et al. Migraine with and without aura in relation to the menstrual cycle and other hormonal milestones: a prospective cohort study. Cephalalgia. 2023;43(6). PMID 37259230.
- Martin VT, Pavlovic J, Fanning KM, Buse DC, Reed ML, Lipton RB. Perimenopause and menopause are associated with high frequency headache in women with migraine: results of the American Migraine Prevalence and Prevention Study. Headache. 2016;56(2):292-305. PMID 26797693.
- Meng SH, Zhou HB, Li X, et al. Association between dietary iron intake and serum ferritin and severe headache or migraine. Front Nutr. 2021;8:685564. PMID 34295917.
- Reddy N, Desai MN, Schoenbrunner A, Schneeberger S, Janis JE. The complex relationship between estrogen and migraines: a scoping review. Syst Rev. 2021;10(1):72. PMID 33691790.
- RIVM and VZinfo. Migraine: figures and context. Available via vzinfo.nl.
- Thuisarts. Migraine. Available via thuisarts.nl.
- Richtlijnendatabase. Sex hormones and migraine, headache guideline. Available via richtlijnendatabase.nl.
Every blood test result at Lunara includes a professional assessment by a BIG-registered doctor. For treatment decisions, discuss your results with your GP.
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