Sex-specific considerations in migraine therapy

Migraine is a highly prevalent and disabling neurovascular disorder characterized by recurrent episodes of moderate to severe headache, often accompanied by nausea, photophobia, and phonophobia. A prominent feature of migraine is its disproportionate burden on women, as evidenced by a higher prevalence, frequency and disability, relative to men. These differences are largely attributed to the modulatory effects of sex hormones on migraine pathophysiology. While the cyclic fluctuations of estrogen across reproductive milestones are known to significantly influence migraine onset and severity, far less is known about how sex hormones shape therapeutic response. Currently, the role of hormonal status in determining treatment efficacy remains poorly studied and represents a critical gap in the field. This narrative review synthesizes the current knowledge on the potential mechanisms underlying the higher prevalence in females. It further discusses the sex-specific responses to pharmacological therapies, as well as hormone-based interventions such as contraceptives and hormone replacement therapy. Special attention is given to female-specific migraine phenotypes, such as menstrual migraine, and to therapeutic implications across the female reproductive lifespan. Finally, we identify major gaps in current research and underscore the urgent need for sex- and gender-stratified approaches to optimize treatment and advance precision medicine in migraine care.