Women and migraine
In 1938, Harold Wolff and John Graham demonstrated ergotamine tartrate’s dramatic effect on migraine pain, confirming its somatic basis. But even as a fragmented professional headache community galvanized around vascular explanations, Wolff’s ideas about the "psychobiologic constellation" cemented emerging ideas about migraine and personality, and particularly that migraine attacked perfectionist, driven women. Graham proposed that migraine treatment should be primarily behavioral, teaching patients to avoid or withstand stresses. Of thirty illustrative examples in Graham’s book, twenty-eight described women.
Psychological and vascular explanations lost ground during the 1970s, as it seemed increasingly likely that neurological processes were responsible for migraine. Using community studies, demographers were attempting evidence-based prevalence calculations. While these suggested that migraine was two to three times more prevalent among women, researchers pointed out that it was still impossible to accurately determine population-level prevalence without an accurate, widely-accepted definition.
The International Headache Society (founded in 1981) published its International Classification of Headache Disorders (ICHD-1) in 1988. This enabled researchers for the first time to produce prevalence studies based on internationally accepted, clinically useful criteria. In 1995, Birthe K. Rasmussen, a Danish neurologist, confirmed that women were three times as likely to experience migraine in their lifetime as men.
Our understanding of migraine’s relationship to sex and gender continues to evolve. Anne MacGregor and colleagues have demonstrated that menstrual attacks (accounting for more than half of migraine in women) are longer lasting, more painful, less responsive to treatment and associated with greater disability than non-menstrual attacks. Significantly, menstrual migraine attacks tend not to include aura symptoms. Only around one in eight women with migraine experience visual aura, compared with around one in three men. Such statistics help explain why late-nineteenth and early-twentieth-century physicians who required aura to confer diagnostic certainty believed that women were only slightly more disposed to migraine than men.
In short, making direct links between sex or gender and migraine relies on a particular model of what migraine is, and what symptoms count in its diagnosis. These ideas have changed a great deal, and no doubt will continue to do so, as we continue to discover more about this extremely common disease.
About the author
Dr Foxhall is a medical historian, and the author of Migraine: A History. She has a PhD in the History of Medicine from the University of Warwick, and has held lecturing and research positions at the Universities of Manchester, Leicester and King’s College London. Website https://kfoxhall.com. Twitter: @historikat.
The author reports no conflicts of interest concerning the subject matter of this article. The research on which this article is based was funded by a Wellcome Trust (UK) Postdoctoral Fellowship in Medical History and Humanities (Grant No. 091650).