Almost everyone has had a headache at some time in his or her life. Most headaches are primary—that is, not related to an underlying disease. If you get headaches, you may be predisposed to them due to genetics, your perception of the stressors in your life, your hormones, or your metabolism. Some headache sufferers experience migraines, which can cause pain when they play sports, when the weather changes, or even when they have an orgasm.

After puberty, migraines are much more common in women than in men, and they have been linked to hormonal changes. In fact, migraines are associated with menstruation in 60 percent of women. These are called menstrual migraines. A menstrual migraine may be associated with either deficient estrogen levels or with the changing hormonal levels that are a normal part of menstrual cycle, both of which may become exaggerated during perimenopause. Once the hormonal instability of perimenopause is over, migraines often improve or disappear.

A migraine headache is diagnosed when the sufferer has throbbing, intense pain, usually on one side of the head that is moderate to severe. The pain often occurs near the eye of the affected side, and can be accompanied by visual disturbance and sensitivity to light, sound or odors. A "classic migraine" is often preceded by an aura. When no aura is present, the migraine is called "common." Migraines can be disabling and may last for hours, days or even weeks.

Scientists have not yet completely unraveled the causes, but there are many triggers that can set off a headache or migraine. Migraines can be triggered by a wide variety of stimuli. Here are some of the most common triggers:

• Excessive estrogen
• Birth control pills and hormone replacement
• Hormonal changes during perimenopause or cyclic changes
• Stress
• Emotional distress, including anger, anxiety, frustration
• Food sensitivities/allergies, especially to caffeine, foods containing tyramine (chocolate, alcohol, organ meats, sour cream, yogurt, yeast extracts, aged cheese, soy sauce), red wine, peanuts, foods containing nitrites (smoked fish, corned beef, bologna, pastrami, pepperoni, bacon, hot dogs, sausage), monosodium glutamate (MSG), and aspartame
• Poor eating and sleeping patterns
• Medications
• Physical exertion
• Glare
• Noise

The best way to determine your triggers is to keep a headache journal. Keeping a record of what you eat, what activities you are involved in, any medications you are taking, and your diet, exercise, and sleep patterns is a good place to start. You may also want to notice any heralding sensations, including where you are when you get a migraine. Are you at work under glaring lights, or stuck in traffic on your way to pick up your children from school? Write everything in your journal and you may start to see patterns emerge.

If you have any concerns about your headache or migraine symptoms, see your health care practitioner. You doctor may want to talk to you about triggers and may suggest an evaluation that could include a psychological exam, blood tests, electroencephalography (EEG), computed axial tomography scan (CAT) or magnetic resonance imaging (MRI).

Because so many different variables can trigger a migraine, it is quite possible to alleviate your migraines through any number of different routes. But the goal is the same: to normalize the excitation in the brain through normalizing hormones and neurotransmitters. Here are some options:

• Avoid estrogen overdose: If you are on estrogen and having migraines, talk to your health care practitioner about decreasing your dose or changing the type of estrogen you are on. Some women are so sensitive to estrogen that they cannot take it in any form without getting headaches. By all means, get off Premarin—it is metabolized into biologically stronger estrogen than the parent compound, making it more apt to cause headaches than the other estrogens, such as estrone and 17-ß-estradiol (the type found in all the patches and in Estrace).¹
• 2% natural progesterone cream: The estrogen dominance that is so common during perimenopause can trigger a migraine, due to estrogen’s excitory nature. Often, 2% bioidentical progesterone cream is all you need to relieve premenstrual or menopausal migraines. Apply one-quarter to one-half teaspoon 2% progesterone cream on your skin daily, starting at least three to four days before your period is due. Those who don’t know when their next period is coming can use the cream daily for at least three weeks per month. To thwart an oncoming migraine, apply one-quarter teaspoon every 15 minutes. This can sometimes abort a migraine because of progesterone’s known ability to calm neurons by acting on the GABA receptors in the brain, much like Valium.²
• Avoid synthetic progestin: Synthetic progesterones, collectively termed progestins, can cause blood vessel constriction. Avoid Provera, Prempro and the various combination patches, such as OrthoPrefest and Activella.
• Medication: If you feel a migraine coming on, the most often used and effective medications are sumatriptan nasal spray or rectal indomethacin. Sumatriptan selectively activates one specific serotonin receptor in the brain and thus helps modulate the effects of this powerful neurotransmitter. The sooner you use one of these medications, the better your chance of aborting the symptoms of migraine. Medicines used to abort an attack should not be taken by mouth because the stomach empties more slowly during a migraine, and also because nausea and vomiting may result.

At the first sign of a migraine (usually one of the neurological symptoms, such as eye disturbance), go to bed in a darkened room or use an eye pillow to cover your eyes. Put a hot water bottle on your hands and an ice pack behind your neck. Keep your feet warm. Cooling the blood traveling to the brain through your neck and warming your hands helps prevent the powerful vasoconstriction and rebound vasodilation that results in headache pain. By doing this, I’ve been able to abort my own migraine attacks.

Avoid trigger foods: If eliminating these foods makes no difference, eliminate the "second tier" allergy foods—wheat, sugar, corn, and dairy—for a two-week period of time. (You can do this one food at a time.) Make sure you read labels; corn syrup is added to all kinds of foods, for example.

Take high-quality supplements, including:

• Magnesium, which has been shown to help prevent migraine because of its calming effect on nerves.³  The usual dose is 400–800 mg per day.
• EPA and DHA (fish oil). Studies in patients with severe intractable migraine demonstrated very significant reduction of headache when these individuals supplemented their diets with fish oil daily for three weeks.⁴  The dosages used were quite high (EPA 2.7 grams and DHA 1.8 grams daily), but if you’re also taking magnesium and a good multivitamin, plus working on your stressors, etc., you can get a good effect from a lower dose.

Try herbs, such as:

• Feverfew (Tanacetum parthenium), the most popular herbal remedy for the prevention of migraines. Regular use of this herb has helped many people avoid migraines. It works by preventing the release of the vasoactive peptides that are involved in vasodilation following vasoconstriction. Look for a brand that has adequate levels of parthenolide, the active principle (level should be 0.25–0.50% parthenolides).⁵ 
• Butterbur (Petasites hybridus), which has been shown to significantly decrease the frequency, intensity and duration of migraines (about 50 percent decrease after 12 weeks). The dose is 50 mg, twice per day.⁶

Avoid or transform potential life stressors: Your job, relationship, or living environment may have aspects that trigger migraines. To find out which stressors may cause you to develop a migraine, I suggest you keep a journal. If and when you get a headache, think back over the prior three days. What went on? Who was visiting? What were you doing at work or at home? Were you angry at someone and afraid to let it out? Was a child, a relative, or a co-worker bothering you in some way? If you record these factors consistently, a pattern will very often emerge that you can then take steps to change.

Change your perception: I developed classic migraines at the age of 12 and had one or two headaches per month until my sophomore year in college. I am definitely a "migrainous" personality. When I was younger I pushed myself mercilessly in school and many other activities. My migraines resolved for nearly 20 years once I was in my early twenties, which happened "miraculously" after a sophomore slump in college. The stress of critiquing a poem by Keats pushed me over the edge and I momentarily considered throwing myself in front of a car. Sanity quickly returned as I realized I’d probably just break a leg and still have to go to the library—but on crutches. I called my parents and told them the stress was simply too much. My dad said, "Quit. Come home." Something in me snapped into place. I realized that I had a choice. I chose to stay. My change in perception changed my physiology—my migraines went away almost entirely. I’ve had only three since that time, and none as severe as in my teens. They returned occasionally during perimenopause, probably due, in part, to fluctuating hormones. However, I have noted that my migraines have nearly always been triggered by a kind of relentless perfectionism that manifests when I am trying to do too much in too little time—with no rest and with no breaks. I know that this type of stress raises norepinephrine levels in the blood, which, in susceptible individuals, can trigger a migraine.

Take regular breaks from repetitive tasks: Taking needed breaks can help reduce strain on sensitive nerves in the neck. If you sit at a computer or work at a job that involves a lot of physical exertion, be sure to gently stretch and flex your neck muscles.

Maintain consistent eating and sleeping patterns: Try to wake up and go to sleep at the same time every day, even on weekends and vacations. Avoid letting too many hours pass between meals, or skipping meals. This can wreak havoc with your blood sugar and start a cascade of hormonal changes in the body that can trigger a migraine.

Practice relaxation: Take a full, deep breath. Hold it for 5–10 seconds and then slowly breathe out. Repeat this ten times. Close your eyes and picture a certain muscle group. Tighten the muscle for a few seconds, and release. Do this for your entire body. Try to visualize that your muscles are becoming so light you could float away. For more information, see The Relaxation Response, by Herbert Benson, M.D.

Try biofeedback: Biofeedback training is often very useful in helping individuals learn how to relax, thus preventing the cascade of neurotransmitter-governed changes that can trigger a migraine. Some studies suggest that 50 percent or more of those who learned and applied biofeedback were able to decrease their migraine attacks. Look in your Yellow Pages under biofeedback to find a practitioner near you.

Stop smoking: Smoking causes blood vessel constriction.

Exercise regularly: Brisk walking or another form of moderate aerobic exercise that you enjoy can help stave off migraines and may help reduce the severity of future attacks. Part of the reason is that exercise stimulates pain-regulating hormones in the brain.