Evaluating the Prevalence of Migraine Headache among Patients with Female-Pattern Baldness

Migraine is a persistent neurological disease that is determined by pulsatile and often unilateral headaches that get worse with physical activity and can be accompanied by photophobia, phonophobia, nausea, vomiting, and usually cutaneous allodynia (1). Migraine is the most recurrent neurological chief complaint in primary care. The last Global Burden Disease study showed that migraine stands second among the world's causes of disability and in first place among young women (2). Androgenetic Alopecia (AGA) is the most prevalent cause of hair loss globally, which includes 30-50% of men (male pattern hair loss or MPHL) and about 30% of women (female pattern hair loss [FPHL]) with a similar mechanism. According to AGA theory, oxidative stress leads to microinflammation in the perifollicle by accumulating pro-inflammatory cytokines. Additionally, OS and high androgen levels work together and interfere with the Corticotropin-releasing hormone function and cortisol levels (3).

Several studies have pointed to migraine headaches and female-pattern baldness as sex-conditioned inherited disorders. Considering the role of sex hormones (androgen) in female-pattern hair loss as a classic example of a sex-conditioned inherited disorder, Wang et al. proposed that the disproportionate distribution of migraine among men and women may be in a similar way affected by serum levels of sex hormones (in this case, estrogen) (4). Lemos et al. also identified gender as a contributing risk factor for migraine (5). In the same way, a review in 2022 highlighted the role of sex hormones, especially estrogen, in migraine (6).

Based on previously mentioned studies and since hormonal changes are considered risk factors for migraine, this study aims to evaluate the unstudied prevalence of migraine headaches in women with AGA.

The limitation of this study was the small population that was included and the lack of measurement of Androgen levels. Thus, further studies should be conducted with larger populations and androgen level measurements to get more accurate results and judge precisely.

The relationship between migraine and female pattern hair loss is unclear. Still, migraine affects women much more commonly than men, and a relationship between these two disorders is to be suspected, considering the role that sex hormones play in the occurrence of both male and female AGA.

Both migraine and AGA have different incidence rates in different stages of a person’s life. While in the present study, the onset of hair loss appeared to range from 13 to 60 years (14 to 38 years in patients with migraine), migraine gradually increases with age, reaching its peak during the fourth decade of an individual’s life before starting to decline (11). FAGA, on the other hand, continues to increase with age, starting from 3 - 12% after puberty and before the age of 40, going up to 29 - 56% in women above 70 (12). Several studies have mentioned sex hormones playing a role in the incidence of migraine. Particularly, estrogen has been found to affect the pathogenesis of this headache disorder greatly. For instance, discoveries show that estrogen withdrawal is the leading cause of menstrual migraine, and estrogen level variations have a role in migraine pathophysiology (12). In addition, in a recent study, about 60% of women reported their migraines to be associated with menses (13). However, in another study consisting of 85 females with MM, despite 35.3% of them reporting headaches by the end of menstruation, it was suggested that this type of headache is most probably related to transient anemia caused by blood loss instead of hormonal changes (14). On the other hand, migraine with aura is believed to be much more related to high estrogen levels, unlike MM (15). While the mechanisms by which sex hormones affect migraine are beyond the scope of this paper, findings indeed suggest both male and female hormones have an important effect on the incidence of migraine and other primary headaches (15). The etiopathogenesis of FPHL is quite complex, with genetic, hormonal, and environmental factors playing a key role. The role of androgens in the development of FPHL is not yet clear. Female pattern hair loss occurs in females with normal levels of circulating androgens, and a genetic predisposition may be involved in women without elevated androgen levels. This genetic disposition permits normal circulating androgen levels to act on follicular target cells, especially sensitized by binding to specific intracellular androgen receptors (16). The case group had a 70% positive family history of AGA, while the control group had 4%. FPHL may also be caused by hyperandrogenism, polycystic ovaries (PCO), and, to a lesser extent, increased androgen/tarragon ratios in women (17). Although some female hormones have been mentioned in the etiology of migraine, androgens have gained very little attention. Studying migraine and serum levels of androgens, Mattson P. found no evidence linking to a connection between different serum levels of androgens and the occurrence of migraine (18). In our study, no significant correlation was observed between migraine and AGA. Furthermore, a cross-sectional study focusing on allopregnanolone, progesterone, and testosterone reported that serum levels of progesterone and testosterone stayed the same in MM and postmenopausal migraine. In contrast, low allopregnanolone levels seemed to be significantly correlated (19). A common feature of PCO is AGA, though it is not as common as hirsutism17. A study in the USA reported the prevalence of PCO to be 22% in women with AGA (20). Regarding hirsutism, Birch et al. found that women with this disorder, either with or without FPHL, had a significantly increased BMI, which was shown to be irrelevant to FPHL (21). In addition, BMI was not found to maintain any significant correlation with age at onset of hair loss in any participants. In contrast, the number of participants in our study was partially based on the prevalence of PCO. A similar earlier study also concluded that migraine and PCO are not closely related (10). The few significant results we encountered were that in patients with FPHL and migraine headaches, the higher the Ludwig score, the more the patient suffered headaches with higher VAS scores. Moreover, menstrual-related migraine headaches were significantly more prevalent in the control group than in patients with FPHL (P = 0.005). This can partially be explained by either the frequent use of finasteride in FPHL patients or the supposed stronger presence of anovulatory cycles in these patients. Delaruelle et al. showed that almost half of the female migraine patients report an association between headache and their menstrual cycle based on the “Estrogen withdrawal hypothesis.” Depending on whether migraine occurs exclusively during the perimenstrual period or also at other times, the International Headache Society (IHS) distinguishes a pure menstrual migraine from a menstrual-related migraine (16). Although the onset of hair loss appeared to happen at a lower median age in women with migraine (23.4 vs. 26.3), the present study did not face significant differences in the prevalence of migraine in women with AGA compared with those without this disorder. A limitation of this study includes the number of available participants and the lack of serum hormonal assay in patients and control group. Moreover, some patients might not have properly filled out the questionnaires. While a decent understanding of the relationship between migraine and AGA, along with sex hormones, has not been properly established, it is advised that future studies with larger databases, including complete detailed sex hormonal assays, be conducted to help shed light on this matter.