Migraine headaches can be incredibly debilitating. In my own experience, migraines led to regular absences from work, missed social occasions, and a growing fear of fully participating in life in case something I did turned out to be an inadvertent trigger. By the time I sought help, I was experiencing 72-hour migraines every 21 days, and feeling worn out and incredibly stressed in between. It was no way to live, yet I could not see a clear way to improve my situation.

Luckily, I worked with a wonderful practitioner who helped me begin to get to the root causes of my migraines, and inspired me to study nutrition! Now, more than five years later, my migraines are much less frequent and severe, and do not last nearly as long. I continue to learn about my body, and to navigate the inconsistencies that can occur with perimenopause.

One pattern that became immediately evident was that my migraines tended to align with a time in my menstrual cycle when estrogen was dropping – just after ovulation or right before my period. I had not paid a great deal of attention to this in the past, as I had been taking birth control for nearly twenty years and was not really in touch with my cycle.

Supporting hormone balance and healthy estrogen metabolism became an important priority. I needed to ensure that I was getting enough water, that my blood sugar was as stable as possible, that I was having regular bowel movements, and that I was giving my body the nutrients it needed to properly break-down and remove estrogen and toxins. I also needed to find ways to address coping mechanisms and patterns of behaviour that promoted stress and tension. The body releases a cascade of chemicals in response to stress that can exacerbate hormonal imbalances.

These changes were incremental in nature, but I began to experience some improvement almost immediately. This inspired me to keeping working to identify and address other potential contributing factors. Over time, I learned that I also needed to reduce exposure to external toxins that might be contributing to my hormonal imbalance, or acting as a migraine trigger in and of themselves. These included chemicals that can disrupt our endocrine system, many of which are found in common household products, and heavy metals such as lead and mercury. An analysis of my hair tissue pointed to higher-than-normal levels of both of these toxic metals.

These are all areas of consideration that I will expand upon in future posts, but I want to highlight another possible contributor to migraines: low iron. The changes I discussed above have led me to reduce and almost eliminate migraines that were occurring after ovulation or just before my period. My quality of life has improved tremendously, and I feel A LOT better most of the time. However, migraines are complex and cannot easily be reduced to one root cause. There can be a constellation of factors that act as triggers.

In tracking my more recent migraines, I began to notice that they were sometimes occurring closer to the end of my period, rather than at the beginning or after ovulation. I also noticed that my period was much heavier than it had been in the past. Hormonal fluctuations are still an important part of this picture, but what I hadn’t thought much about was how a loss of iron might also be a contributing factor.

I decided to dig a little further into the research. I found a number of studies that demonstrated or discussed a possible association between iron deficiency and migraine headaches in adults. Some of these studies were specifically related to iron-deficiency anemia (IDA) and its relationship to menstrual migraines, while others considered a deficiency of iron outside of this context.

For instance, a cross-sectional examination of involving data collected as part of the National Health and Nutrition Examination Surveys in the U.S., found that most women aged 20–50 years consumed less iron from their diet than the recommended amount (RDA). This study suggested an inverse association or opposite relationship between dietary iron intake and severe headache or migraine for women in this age group. (Meng et al.)

A 2017 article in the aptly named publication, Headache, provided another possible clue. The authors of this study described how for several years they had noticed that some women were complaining of migraines occurring at the end of their period. They felt this timing might have something to do with menstrual blood loss and levels of a blood protein called ferritin, which stores iron and releases it when there is demand from our tissues. Decreased levels of ferritin in the blood can precede other signs of iron deficiency.

When the authors examined blood ferritin levels, they found that they were below their generally accepted lower desirable limit of 50 ng/mL (you may also see this as ug/L on lab results) in 28 out of 30 subjects. This prompted them to propose criteria for a new category of migraine called “end-menstrual migraine” (EMM), which refers to a “predictable migraine headache . . . that occurs immediately after or toward the end of menstrual bleeding” (Calhoun and Gill). The authors also noted that subjects had other migraines in addition to EMM, including menstrual-related migraines in a majority of cases. They suggested that, “EMM is not hormonally mediated, but rather that it is causally related to menstrual blood loss, resulting in a brief relative anemia with consequent migraine” (Calhoun and Gill).

This is another piece of the puzzle, but it is important not to over-simplify what is a very multifaceted condition. Research is also exploring the complex relationship between estrogen, dopamine, and iron metabolism, which may have implications for the mechanisms underlying some migraines, but further investigation is required. It is also important to remember that we are all biochemically unique. The research studies discussed are not definitive, but rather provide us with some possibilities that can be considered in the context of our own individual situations.

So, what might be some things for us to consider if we are contending with migraines near the end or just after our period?
• How heavy is my flow?
• Am I getting enough dietary iron to help offset a heavy period?
• What are my blood ferritin levels? (your doctor or ND can help you with this)

We can also consider and track other contributing factors such as certain foods, lack of sleep, weather, stress, hormonal imbalances, and impaired detoxification, and begin to create a profile that can help us to understand some of the possible root causes or imbalances behind our migraines. This kind of reflection allows for a more in-depth discussion with your practitioner, and may help lead to some additional or different supporting interventions.

One immediate step is to ensure that we are getting enough iron from our diet, especially if we have a period. The recommended dietary allowance (RDA) of iron for females between age 19 and 50 is 18 mg per day.

Key food sources of iron include:
• oysters
• mussels
• organ meats
• beef
• lentils
• spinach
• potato with skin
• cashews
• pumpkin seeds
• blackstrap molasses

It is also important to distinguish between heme and non-heme food sources of iron. Heme iron is found in meat, poultry, and fish and its absorption is more straightforward than that of non-heme iron. Non-heme iron is contained in plant sources. Various food components can enhance or inhibit its absorption. Vitamin C, citric acid, and meat, poultry and fish all enhance the absorption of non-heme iron, whereas phytic acid contained in nuts, legumes, and whole grains may inhibit its absorption. Certain compounds in coffee and tea also act to inhibit absorption of non-heme iron. It can be more challenging to obtain sufficient dietary iron from plant-based sources alone, so it is important to be aware of which plant-based foods are highest in iron, and how best to maximize absorption.

I hope this post helps to introduce another potential consideration when working to identify and address possible contributing factors to migraine. This kind of approach takes time and patience, but it can also be very rewarding. As a holistic nutritionist, it is my pleasure to support clients as they work to put the pieces together on their own journey toward health and wellness.

Sources:

Calhoun, A.H. & Gill, N. (2017) Presenting a New, Non-Hormonally Mediated Cyclic Headache in Women: End-Menstrual Migraine. Headache, 57, 17-20. https://doi.org/10.1111/head.12942

Gür-Özmen, S., & Karahan-Özcan, R. (2015). Iron Deficiency Anemia Is Associated with Menstrual Migraine: A Case–Control Study. Pain Medicine, pnv029. https://doi.org/10.1093/pm/pnv029

Lee, H.-S., Lee, S.-Y., Huang, W.-T., Chen, S. C.-C., & Yang, H.-Y. (2021). Risk of migraine in iron deficiency anemia patients with or without iron supplementation usage: A nationwide database analysis. Archives of Medical Science. https://doi.org/10.5114/aoms/124191

Linus Pauling Institute, Micronutrient Information Center, Iron: https://lpi.oregonstate.edu/mic/minerals/iron

Meng, S.-H., Zhou, H.-B., Li, X., Wang, M.-X., Kang, L.-X., Fu, J.-M., Li, X., Li, X.-T., & Zhao, Y.-S. (2021). Association Between Dietary Iron Intake and Serum Ferritin and Severe Headache or Migraine. Frontiers in Nutrition, 8, 685564. https://doi.org/10.3389/fnut.2021.685564

Mohammadi, M., Ghasemi, M.,Khorvash, F., Maddahian, P., (2016). The Association of Menstrual Migraine with Iron Deficiency and Its Induced Anemia. Caspian Journal of Neurological Sciences, 2(7), 19–24. https://doi.org/10.18869/acadpub.cjns.2.7.19

Rashid, S., Haq Nawaz, K., Athar, M. H., Fakhar, A., Hakeem, F., & Manzoor, N. (2022). Frequency of Iron Deficiency Anemia in Young Females with Migraine. Pakistan Armed Forces Medical Journal, 72(SUPPL-2), S371-74. https://doi.org/10.51253/pafmj.v72iSUPPL-2.2977