FAQ Episode 66: Endometriosis and Migraine

Frequently Asked Questions about Natural Migraine Relief

I was prompted to write this post recently when I recieved a Christmas card from one of my many patients over the years whose previous diagnosis and treatment of endometriosis was a key part of their improvement with migraine headache. Mandy (not her real name) was in her mid-20s when her migraines began. She had always had heavy but regular periods, starting at age 13. During her college years she had began to experience episodic pelvic pain and abdominal cramps, which were worse during her period. Then the migraines began. They were worse in the late cycle, going into her first few days of menstrual flow. Going on birth control pills was slightly helpful, maybe 30-40% better. I first saw her in her late 20s, and at that time she was suffering a fair amount of disability due to migraines for five to six days each month. She had been married four years and had gone off birth control, but was unable to conceive. She was also was having pain with intercourse. An initial trial of cycled progesterone support was maybe 50% helpful with the late cycle headaches and pelvic pain. Her gynecologist and I suspected underlying endometriosis and advised her to have a laparoscopy. There they found several endometrial implants, and were able to clear them during the procedure. We continued progesterone support to limit the effects of her long-term estrogen dominance. We also added some measures specific to her situation from the Migraine Action Plan in my Natural Migraine Relief course. She has subsequently had two successful pregnancies and has only rare headaches, which respond well to as-needed triptan drug therapy. Her story is only one example of the many thousands of women who have a cause and effect overlap between endometriosis and migraine headache.

Endometriosis: an undiagnosed epidemic

Endometriosis is a relatively common problem, affecting an estimated five–10% of women during their reproductive years. It occurs when tissue from the uterus grows in other parts of the body, such as the ovaries, bowels, or bladder. Symptoms of endometriosis can include pain during menstruation, sexual intercourse, bowel movements, and urination. Because related symptoms of chronic pelvic pain, abdominal bloating, nausea, fatigue, depression, anxiety, and infertility can be hard to pin to one specific diagnosis, the average woman with endometriosis is not diagnosed for seven years. Some studies have reported delays of up to 11 years between the onset of symptoms and diagnosis. Endometriosis is also a major cause of infertility. If you are unable to conceive, you are six to eight times more likely to have endometriosis than women who can conceive. Years of effort including rounds of IVF may occur before the true impediment to conception is discovered.

Endometriosis is also a fairly common comorbid disorder to migraines. The 2021 Endometriosis in America survey¹ found that 43% of those with endometriosis also suffered from migraines, and another study showed that migraine is 1.7 times more common in women with endometriosis than in those without the disease.²

A comorbid condition is one where two disorders exist in the same patient. An useful question to ask in these cases is if the two problems have common root causes. For a general discussion on this topic see myFAQ Episode 4: Migraines and co-morbid medical conditions. If this relationship exists, there may be therapeutic measures applicable to both conditions. Let’s consider what causes and therapy options these two serious medical problems might share.

Potential root cause factors common to endometriosis and migraine

While there are almost certainly similar underlying genetic predispositions shared by these conditions, they are as yet under defined and without specific therapy options. So, let’s focus on two areas where we may be able to take direct action:

1. Hormonal imbalances

   Both migraine and endometriosis can share a common hormonal denominator: that of estrogen dominance. And in many cases, this is not primarily a matter of excess estrogen, but more of progesterone deficiency. Often this deficit has been a problem since the onset of regular cycles back in one’s teens. When this is true, the individual can often trace a history of other estrogen dominance related symptoms, even going back years or decades, such as:

   -heavy and painful periods

   -cyclic ‘PMS’ with fluid retention, breast tenderness, mood swings, food cravings, etc.

   -headaches that have cyclic components, happening more frequently at the end of the month and at times into the first one to two days of flow.

   -fibrocystic breast changes.

   -uterine fibroids.

   In this setting, I usually start with two simple measures for front line therapy that you can do at home:

   -topical progesterone support can be very helpful, both through the month and especially in the '“luteal phase” of the latter third of the cycle.

   -using cruciferous extracts to reduce the production of “pro-proliferative” estrogens. These estrogen metabolites can exaggerate an estrogen

   dominant condition.

   I’ll go into details on the how-to on these in the action section below. At times it can be helpful to find a physician versed in bioidentical hormone support therapy. Paid subscribers can review options for this in Lesson 24: Getting another opinion: finding an integrative or functional medicine minded practitioner.

2. Inflammation

   Both migraine and endometriosis are associated with elevated levels of underlying inflammation. Many women with endometriosis experience migraine symptoms after the onset of endometriosis rather than beforehand. One study demonstrated that 78.8% of women experienced migraine attacks after their endometriosis diagnosis versus the 21.2% who had migraines before their diagnosis.³ For migraine, the inflammation can be a direct result of the endometrial implants undergoing cyclic activity in locations where they don’t belong, in locations within the abdominal cavity. There, the local effect of menstrual blood and related prostoglandin activity cause local and blood bourne inflammation that can precipitate a migraine event. For Mandy, whose story leads this article, endometriosis related inflammation was a significant factor promoting her headaches.

   If this is happening, the #1 thing to do is to get it properly diagnosed. I cannot count how many women I’ve seen who have suffered from both endometriosis and migraines and turned out to have been under medical care for many years before getting a defined diagnosis for their condition. Endometriosis almost always requires a surgical procedure to effectively define and treat. Less severe cases may respond to hormonal therapy to limit ovarian hormones and suppress menstrual cycles, but for many women this route is neither sufficient for diagnosis or effective enough for suppression of inflammation and pain.

   Moving ahead to a procedure like laparoscopy is not a simple decision for either the patient or surgeon. It requires general anesthesia and can be expensive, depending on insurance. For instance, per an estimate in Out-of-Pocket Costs: Laparoscopic Surgery for Endometriosis⁴ at endometriosis.net:

   -Medicaid recipients: 69% paid less than $500

   -Medicare recipients: 33% paid less than $500

   -Private insurance: 42% paid between $500 and $3,999

   -Military coverage: 19% paid between $500 and $3,999

   -No insurance: 23% paid $8,000 or more

   But whatever the obstacles to therapy, if you have significant endometrial implants that are not diagnosed and properly managed, any related inflammation WILL continue, and even your best alternate efforts to clear migraines may prove ineffective. Sometimes you will need to be the one to take ownership of this concern, and press your physician toward the consideration of a laparoscopic procedure. You may even need to get a second opinion.

Action considerations:

1. The first step to optimal treatment is an accurate diagnosis. Whether you suspect having endometriosis, or have a working diagnosis, collaborate with your doctor to confirm as specific a diagnosis and treatment plan as possible.

2. If you have symptoms consistent with estrogen dominance, you may benefit from:

   a) adding daily progesterone support therapy. For over the counter use, a cream dosage of 25-50 mg used daily (used whether on your period or not) is a reasonable starting place. Make sure to rotate application among the four extremities (inner arms & inner thighs) and best done in the PM before bedtime. Make sure the progesterone label states “USP Progesterone” as the active ingredient.

   b) using additional luteal (late phase) progesterone. If you have late cycle dominance symptoms (as discussed above,) and daily progesterone is not sufficient, consider adding another 25-50 mg on those symptomatic days (usually the last five to 10) before the onset of menstrual flow. You may benefit in getting individualized advice from a bioidentical knowledgeble practitioner on the nuances of implementing therapy.

   c) consider taking a daily dose of a cruciferous vegetable concentrate to safely block the production of the most ‘pro-proliferative’ estrogens that worsen dominance effects. A brand I recommend is Nature’s Way “DIM-plus” 100 mg, taken one a day with a meal.

3. Clearing or shrinking endometrial implant tissue will reduce the inflammatory load. Aside from surgical intervention, using focused NSAID’s like naproxen can block associated excess prostoglandins and are typically useful once or twice a day (with a meal) during the two or three days at the end of a cycle directly preceding the onset of menstrual flow.

Almost always, the management of problems that are comorbid to migraine will require managing several overlapping factors, as well as persistance over time. Its rarely an easy path, and I hope you find both the tools and the tenacity to stay the course, and find your migraine relief. Continue to follow these posts for ongoing information and action oriented considerations. Please leave your thoughts or questions about topics you want to hear about in the comments section. Thanks in advance for sharing your insights and concerns with me.

1. Lessons from the 2021 Endometriosis In America Survey: Quality of Life and Coping https://endometriosis.net/clinical/living-coping

2. “Women with Endometriosis Are More Likely to Suffer from Migraines: A Population-Based Study.” Yang, et.al. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3307779/

3. "The Relationship Between Migraine and Endometriosis." Petrrarca, K Association of Migraine Disorders. March 3, 2022.

4. Out-of-Pocket Costs: Laparoscopic Surgery for Endometriosis https://endometriosis.net/clinical/cost-laparoscopy-surgery