Sex differences in migraine prevalence have been recognized for centuries, but researchers are still just beginning to understand the factors that put women at greater risk.

Women are two to three times more likely than men to have migraines. The condition typically hits women hardest in their thirties, when the consequences of days lost to debilitating pain can be tremendous. “This is when women are going through pregnancy and post-pregnancy, taking care of small children and working at their jobs,” says Jelena Pavlovic, a neurologist at the Montefiore Medical Center in New York City. “It’s a time when one builds capital for the rest of their life.”

For more than half of women aged between 18 and 60, the onset and timing of migraines is connected with the hormonal flux of their menstrual cycle. This relationship is well-documented in the literature, according to Anne MacGregor, a clinician specializing in headache and women’s health at Barts Health NHS Trust in London. “There’s been an understanding of this link for centuries,” she says. And yet little research has been done to explore the nature of sex-related differences in migraine or their clinical consequences.

Much of this knowledge gap is attributable to gender bias — a pervasive problem in clinical research. “If migraine affected men at the same rate, we would have much better studies,” says Pavlovic. “A lot of the biases and stigma associated with migraine have to do with it being a disorder of women.” But it is also an undeniably thorny scientific problem, requiring a better understanding of the physiological mechanisms underlying migraine and how hormones interact with these pathways to make women more susceptible to this condition.

A vicious cycle

Young boys and girls are about equally likely to develop migraine. But at puberty, the prevalence in females rapidly escalates. Through adulthood, migraine risk increases in everyone, but it continues to climb more steeply in women. Their risk peaks at around age 35, then gradually tapers off until it declines steeply at menopause. In all, the prevalence of migraine in women is estimated to be around twice that of men.

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