Authors: Meghan Etsey, Mallory Johnson, Dr. Vaishnavi Patel on behalf of the Gender Equity Task Force

With over one billion people worldwide affected in 2021, migraine stands as one of humanity’s most disabling and costly neurological disorders (Dong et al., 2025). Affecting approximately one in nine adults globally, its impact extends far beyond episodic pain to encompass profound physical, psychological, and socioeconomic consequences (Nappi et al., 2022). Notably, migraine demonstrates a striking gender disparity: adult women experience migraine at rates three to four times higher than men and tend to endure attacks that occur more frequently, last longer, and result in greater functional impairment (Rossi et al., 2022; Allais et al., 2020). Moreover, women are disproportionately burdened by the accompanying symptoms, such as nausea, vomiting, and heightened sensitivity to light, sound, and touch, that compound the overall disability associated with each episode (Allais et al., 2020). Together, these patterns highlight migraine as not only a global health concern but also a distinctly gendered disease, warranting deeper examination of the biological, perceptual, and systemic factors driving these inequities.

Among the biological factors contributing to this disparity, hormonal fluctuations, particularly in estrogen and progesterone, play a central role in modulating migraine susceptibility. These hormones influence both neuronal excitability and vascular tone through genomic and nongenomic mechanisms, affecting key neurotransmitter systems and pain-processing networks (Allais et al., 2020). Estrogen in particular plays a complex protective role in migraine pathophysiology by modulating multiple neurotransmitter systems and pain pathways. It enhances serotonergic activity, which helps prevent migraine attacks, while also influencing glutamate, GABA, and opioid systems that regulate pain perception (Nappi et al., 2022). Estrogen upregulates oxytocin production, a neuropeptide with pain-suppressing properties. Estrogen receptors are highly expressed in trigeminal neurons that process pain signals. Additionally, estrogen modulates inflammatory mediators such as calcitonin gene-related peptide and substance P, which are involved in neurogenic inflammation during attacks, and reduces proinflammatory cytokine production (Nappi et al., 2022). In the perimenstrual period, estrogen levels drop, lowering these pain thresholds and increasing vulnerability to migraine attacks.

Yet biology only tells part of the story. Even when women present with classic migraine symptoms, the way their pain is interpreted and addressed in clinical settings reflects deeper systemic gender biases. Research across multiple medical disciplines shows that women’s reports of pain are more likely to be minimized, psychologized, or attributed to emotional causes rather than biomedical pathology (Samulowitz et al., 2018). In migraine care, this can translate into delayed diagnosis, inadequate acute treatment, and a reduced likelihood of receiving preventive therapies compared to men with similar symptom severity (Minen et al., 2016). These perceptual biases carry real clinical consequences: they prolong suffering, delay effective treatment interventions, and limit women’s access to evidence-based treatments that could significantly reduce attack frequency and intensity.

Such disparities are further compounded by the diagnostic challenges inherent to hormone-related migraine. Menstrual migraine and perimenopausal migraine, for example, remain underrecognized despite their high prevalence, in part because many clinicians receive limited training on how hormonal fluctuations impact disease expression (Vetvik & MacGregor, 2017). Women may be told their symptoms are part of “normal” hormonal shifts rather than manifestations of a serious neurological disorder. This normalization not only delays targeted interventions but can also reinforce the misconception that women’s migraine is an inevitable or unavoidable consequence of biology, rather than a condition that warrants precise, individualized interventions.

Addressing these inequities requires a multipronged, gender-responsive approach. First, the adoption of gender-sensitive diagnostic criteria can ensure that the unique presentation patterns of women’s migraine, especially those linked to hormonal cycles, are systematically recognized rather than overlooked (Lay & Broner, 2009). Updated criteria that integrate menstrual patterns, perimenopausal changes, and the distinct symptom clusters more frequently reported by women would facilitate earlier and more accurate diagnosis.

Second, improving clinician education is essential. Training should equip healthcare providers to understand the hormonal influences of migraine, differentiate menstrual migraine from other headache disorders, and implement cycle-based preventive strategies when appropriate. Equally crucial is education on recognizing implicit gender bias, helping clinicians identify and counteract tendencies to minimize women’s pain or misattribute symptoms to emotional causes.

Third, expanding the inclusion of women in clinical trials remains a critical step. Historically, women, particularly those of reproductive age, have been underrepresented in neurological and pain research, limiting our understanding of how therapies perform across hormonal states (Lenert et al., 2021). Ensuring robust female participation will generate evidence that more accurately reflects women’s physiology and treatment responsiveness, ultimately leading to more effective and individualized therapies.

Finally, supporting patient self-advocacy empowers women to navigate a system that has not always served them equitably. Encouraging patients to track symptoms across their menstrual cycles, bring detailed records to appointments, inquire about preventive options, and seek second opinions when concerns are dismissed can help counteract system-level gaps. Clinicians and health systems can reinforce these efforts by providing accessible education materials, shared decision-making tools, and culturally sensitive support resources.

Taken together, these strategies underscore the urgent need for a more equitable, informed, and gender-responsive approach to migraine care- one that recognizes the biological realities, challenges perceptual biases, and dismantles the systemic barriers that shape women’s experiences of this highly disabling condition.

References: 

Allais, G., Chiarle, G., Sinigaglia, S., Airola, G., Schiapparelli, P., & Benedetto, C. (2020). Gender-related differences in migraine. Neurological Sciences, 41(Suppl 2), 429–436. https://doi.org/10.1007/s10072-020-04643- 8 

Dong, L., Dong, W., Jin, Y., Jiang, Y., Li, Z., & Yu, D. (2025). The global burden of migraine: A 30-year trend review and future projections by age, sex, country, and region. Pain and Therapy, 14(1), 297–315. https://doi.org/10.1007/s40122-024-00690-7 

Lay, C. L., & Broner, S. W. (2009). Migraine in women. Neurologic Clinics, 27(2), 503–511. https://doi.org/10.1016/j.ncl.2009.01.002 

Minen, M. T., Loder, E., Tishler, L., & Silbersweig, D. (2016). Migraine diagnosis and treatment: A knowledge and needs assessment among primary care providers. Cephalalgia, 36(4), 358–370. https://doi.org/10.1177/0333102415593086 

Nappi, R. E., Tiranini, L., Sacco, S., De Matteis, E., De Icco, R., & Tassorelli, C. (2022). Role of estrogens in menstrual migraine. Cells, 11(8), Article 1355. https://doi.org/10.3390/cells11081355

Rossi, M. F., Tumminello, A., Marconi, M., et al. (2022). Sex and gender differences in migraines: A narrative review. Neurological Sciences, 43(9), 5729–5734. https://doi.org/10.1007/s10072-022-06178-6 

Samulowitz, A., Gremyr, I., Eriksson, E., & Hensing, G. (2018). “Brave men” and “emotional women”: A theory-guided literature review on gender bias in health care and gendered norms toward patients with chronic pain. Pain Research and Management, 2018, Article 6358624. https://doi.org/10.1155/2018/6358624 

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. https://doi.org/10.1016/S1474-4422(16)30293-9 

Lenert, M. E., Avona, A., Garner, K. M., Barron, L. R., & Burton, M. D. (2021). Sensory neurons, neuroimmunity, and pain modulation by sex hormones. Endocrinology, 162(8), bqab109. https://doi.org/10.1210/endocr/bqab109 

About the Authors

Meghan Etsey, MS4

Meghan Etsey is a fourth year medical student from St. George’s University. She has a Bachelors of Arts in Biology and a Bachelors of Arts in Nutrition and Dietetics from Bluffton University in Bluffton, Ohio. She served as the President of the St. George’s University’s Women in Medicine chapter in St. George, Grenada where she expanded relationships with the community and worked towards educating women and helping the youth. She is also a member of the Gender Equity Task Force and Sex and Gender Health Collaborative Committees within the American Medical Women’s Association. When she is not pursuing medicine, you can find her with her friends and family on different road trips and adventures exploring the world. 

Mallory Johnson, MS4

Mallory Johnson is a fourth-year medical student from St. George’s University. She holds a Bachelor of Science in Forensic Science and a Bachelor of Science in Chemistry from Tiffin University. She worked as an Analytical Chemist at P&G and KAO before medical school. She is passionate about giving back to vulnerable communities and providing equal access and opportunity to medical care. She is a member of the Domestic Violence and Music in Medicine Committees within the American Medical Women’s Association. When she’s not doing schoolwork, you can find her playing her cello, reading cozy mysteries, and playing with her poodles, Gertie and Maple.

Vaishnavi Patel, DO

Vaishnavi J. Patel, DO is an early career family medicine physician. She is passionate about Women’s Health and advocacy, serving on the Executive Board of the American Medical Women’s Association GETF and playing a crucial role in their initiatives to support women in medicine. Her research expertise includes scientific computation, data sciences, and analyzing methods to improve patient outcomes and women’s health. She is a dedicated volunteer for local free clinics and a speaker at various programs focused on patient education and advocacy. She serves as an ambassador of the Gold Humanism Honor Society and is a recipient of the Lifetime Presidential Volunteer Service Award and the Eliza Lo Chin Unsung Hero Award. In her spare time, she enjoys archery, reading, spending time with her family, and spoiling her pets. Her patients describe her as compassionate, thorough, and knowledgeable. Her classmates, coworkers, and mentors describe her as a genuine leader, hard-worker, and a valuable asset to the future of medicine.