Migraine is more common in women than men – but this can mean that men with migraine get overlooked.
The reason migraine is more common in women is mostly attributed to hormonal differences and changes in women, from puberty to menopause. Women have higher and fluctuating levels of the sex hormone estrogen during child-bearing years and lower levels of testosterone.
Estrogen appears to increase the sensitivity of the brain to migraine attacks (lowering the threshold for an attack) but testosterone may be protective. Sex hormones, both estrogen and testosterone, affect the pain experience of men and women in complex ways. The role of testosterone in migraine is not well understood but studies suggest it has a role to play. For example, testosterone levels have been found to be lower in men with chronic migraine than men without migraine.
Men with migraine are less likely to be diagnosed with migraine, which means migraine in men is not always optimally managed. Migraine is sometimes (wrongly) considered to be a woman’s condition, which contributes to underdiagnosis of migraine in men – because men don’t want to have a ‘feminine’ disease and health professionals might not think about migraine as a typical diagnosis for a man. Following on from this, men are less likely to use acute or preventive medications than women, probably because they are less likely to see a health professional for migraine (and get a diagnosis).
Around 7–8% of all people with migraine have chronic migraine (headache on 15 days or more per month) but more men may have chronic migraine than women, especially after the age of 40 (10–12% of men with migraine aged over 40 have chronic migraine compared to 7–8% of women with migraine). Although the reasons for this haven’t been well studied, it could be because migraine is undertreated in men, since optimising acute and preventive treatments can help reduce the transition of episodic into chronic migraine.
Because migraine is more common in women, many clinical trials of migraine treatments have included more women than men, raising the possibility that there may be differences in treatment results for men. Sex-specific differences in migraine preventive treatments have not been studied, except for anti-CGRP monoclonal antibodies (e.g. Emgality). For these medications, no difference in safety or effectiveness by sex has been found. Men appear to tolerate and respond as well or better to triptans as women.
During migraine attacks, women report more non-headache symptoms like nausea, vomiting, sensitivity to light or sound and attacks of longer duration than men. Migraine with aura is less common in men than women, probably because aura appears to be sensitive to higher levels of estrogen.
Women also report higher migraine-related disability than men, but this is frequently measured using the Migraine Disability Assessment score (MIDAS). This is based on five questions, including inability to do household work and missing out on family or social activities. Women with migraine are significantly more likely than men to score highly on these questions, and women are also more likely to undertake household chores and family responsibilities, which could explain this difference.
Men may have less migraine disease but they make up for it by being more likely to have cluster headache, another primary headache disorder with some similar features to migraine. Although much less common than migraine, affecting only 0.1% of the population (compared to migraine, which affects around 16%), it’s described as being one of the most excruciating conditions known to ‘man’.
No matter what the diagnosis, men with headache symptoms shouldn’t tough it out or think that seeking help and treatment for a headache is unnecessary or unmasculine. As we keep saying, migraine is not ‘just a headache’– it’s a neurological condition. You’d go to the doctor for a stroke or a seizure, so do the same for a migraine attack.
Ahmad, S. R. & Rosendale, N. Sex and Gender Considerations in Episodic Migraine. Curr Pain Headache Rep (2022) doi:10.1007/S11916-022-01052-8.
Tsai, C. K., Tsai, C. L., Lin, G. Y., Yang, F. C. & Wang, S. J. Sex Differences in Chronic Migraine: Focusing on Clinical Features, Pathophysiology, and Treatments. Curr Pain Headache Rep 26, 347–355 (2022).
Vetvik, K. G., & MacGregor, E. A. (2017). Sex differences in the epidemiology, clinical features, and pathophysiology of migraine. The Lancet Neurology, 16(1), 76–87.
Vincent K, Tracey I. Hormones and their Interaction with the Pain Experience. Rev Pain. 2008 Dec;2(2):20-4.
Buse DC, Manack AN, Fanning KM, et al. Chronic migraine prevalence, disability, and sociodemographic factors: results from the American Migraine Prevalence and Prevention Study. Headache. 2012 Nov-Dec;52(10):1456-70