A migraine attack is not just a headache, and not all migraine attacks are the same. The symptoms, length and frequency of migraine attacks can vary from person to person, but we know two clear factors that influence migraine: sex, in the biological sense, and gender—the social and cultural differences in how men and women seek and receive care.

Migraine is three times more common in women than men, and women and men experience migraine differently. For example, women are more likely to have longer and more intense migraine attacks and report more migraine-associated symptoms including nausea, visual aura and sensitivities to light or sound.

Women also have higher levels of migraine-related disability, such as requiring bed rest with attacks, having reduced productivity at work or school or remaining impaired for longer following an attack. This chronic, painful disease is the second leading cause of the global burden of disability, and associated economic costs in the United States are an estimated $78 billion per year, with women shouldering about 80 percent of the direct medical and lost labor costs.

A better understanding of the biological and sociocultural influences that impact migraine will improve diagnosis and treatment for both sexes, according to a report we at the the Society for Women’s Health Research published recently. The report summarizes the current research on sex and gender differences in migraine, identifies knowledge gaps and prioritizes areas that merit further attention. By addressing these differences, we can help decrease the large health and economic burden of migraine for patients, families, and society as a whole.

One suspected reason for the disparity in migraine prevalence between women and men is estrogen. During childhood, migraine is more common in boys than girls, but after the onset of puberty, migraine becomes more prevalent in women and remains this way throughout the rest of the lifespan. This suggests that hormonal fluctuations, particularly during a woman’s menstrual cycle, may play a role in migraine attacks.

Corroborating this is a recent study, which found that women with migraine have a faster drop in estrogen levels just before onset of their period than women without migraine. This fast drop in estrogen may be a trigger for migraine attacks. New evidence also suggests that estrogen may play a role in men’s attacks as well. More research to fully elucidate the role of estrogen in migraine for both women and men is needed.

Comorbid conditions are also very common for those with migraine, with women and men having 11 and five comorbid conditions, respectively. Some data suggest that the kinds of comorbidities can differ between women and men, although other data show conflicting results. Importantly, comorbid conditions such as depression and anxiety, which are more prevalent in women, and obesity, which is more prevalent in men, are associated with increased frequency of migraine attacks. The relationship between comorbidities and migraine is not well understood, yet recognizing these differences and incorporating them into the diagnosis can help determine appropriate treatment regimens.

Despite its high prevalence and burden to society, migraine remains a stigmatized disease. This is in part because the disease is “invisible” and predominately affects women, causing migraine to be perceived as less legitimate. The stigma has created gender differences in how women and men seek and receive care.

Women are more likely than men are to talk with their health care provider about their symptoms and to seek care for their attacks in the emergency room or urgent care. This may be because women tend to have more severe attacks or because men are reluctant to consult health care providers because of the feminization of the disease. It is important for patients and providers to recognize these differences to help overcome our biases in migraine and remove current barriers to receiving optimal care.

In our report, the Society for Women’s Health Research outlines priority areas for sex and gender differences in migraine research, care and education, including:

Expanding upon the role of female hormones in migraine across the lifespan;

Improving understanding of the impact of sex and gender differences in comorbidities in migraine etiology and treatment;

Increasing awareness of migraine to better identify and treat the disease;

Improving assessment of migraine’s impact on quality of life for patients, families and society;

Destigmatizing migraine through education for patients, providers, payers, employers and the public.

Sex and gender clearly play important roles in migraine etiology, presentation, treatment and care. We need more research into the differences between women and men in migraine to advance our understanding of the disease and more education to increase awareness of these differences to improve access to care and health outcomes for both women and men.