Migraine risk factors: heredity, hormones, stress, sleep, medications, and causes of chronicity

Migraine risk factors are body characteristics, lifestyle factors, underlying medical conditions, or environmental factors that increase the likelihood of migraine onset, increased frequency of attacks, or the development of episodic migraine into chronic migraine. These are not the same as triggers: a risk factor is long-lasting and increases vulnerability, while a trigger is typically associated with a specific attack, such as sleep deprivation, alcohol, skipping a meal, or the menstrual window. [1]

Migraine is a primary headache disorder, meaning it is typically not caused by a tumor, stroke, or infection. The World Health Organization describes migraine as recurring attacks, typically lasting 4-72 hours, with nausea, vomiting, photophobia, phonophobia, and sometimes an aura. [2]

Risk factors do not necessarily mean the disease is inevitable. For example, heredity or female gender increase the likelihood of migraines, but do not guarantee their development; poor sleep, stress, obesity, or frequent use of painkillers can worsen the course of the disease, but correcting them does not always completely eliminate attacks. [3]

It is important to distinguish between three levels of risk: the risk of experiencing migraine for the first time, the risk of frequent attacks, and the risk of chronicity, when headaches occur 15 or more days per month. The UK National Institute for Health and Care Excellence defines chronic migraine as 15 or more headache days per month for more than 3 months, with at least 8 days having migraine features. [4]

The practical goal for the patient and physician is not to find “1 main cause,” but to understand the personal risk profile: heredity, hormones, attack frequency, sleep, stress, medication load, concomitant anxiety or depression, body weight, caffeine, alcohol, physical activity, and vascular factors. [5]

Concept	What does it mean?	Example
Risk factor	Increases the likelihood of migraines or their worsening	Heredity, female gender, frequent attacks
Trigger	May trigger a specific attack	Lack of sleep, alcohol, skipping meals
Chronicity factor	Increases the risk of developing chronic migraine	Drug overload, obesity, depression
Associated condition	May increase migraine burden	Anxiety, insomnia, obstructive sleep apnea
Non-modifiable factor	Cannot be changed directly	Age, gender, genetics
Modifiable factor	Can be reduced or controlled	Sleep, caffeine, medications, smoking

Sources for the table: American Migraine Foundation, World Health Organization and the National Institute for Health and Care Excellence in the UK. [6] [7] [8]

Heredity, age and gender

Heredity is one of the main factors predisposing to migraine. Modern genetic reviews describe migraine as a disease with a strong genetic basis, including both rare monogenic forms and more common polygenic variants, where multiple low-power genetic factors contribute. [9]

In common migraines, it's not a "broken gene" that's at play, but rather an inherited sensitivity of the nervous system. Genetic factors can influence neuronal excitability, pain processing, susceptibility to aura, response to hormonal fluctuations, and the likelihood of more frequent attacks. [10]

Age also plays a role. The World Health Organization notes that migraines often begin during puberty and typically affect people between the ages of 35 and 45 the most. This explains why migraines have a particularly significant impact on school, work, family life, and social activities. [11]

Female gender is one of the most consistent non-modifiable risk factors. The World Health Organization notes that migraine is more common in women, likely due to hormonal influences; the American Migraine Foundation also lists female gender as a factor associated with worsening migraine. [12] [13]

Migraine in children can present differently than in adults: attacks are typically shorter, and abdominal symptoms may be more pronounced. Therefore, a child's risk of migraine cannot be assessed solely by the adult pattern of "unilateral throbbing pain for 4-72 hours." [14]

Factor	How does it affect risk?	Is it possible to change?
Family history of migraines	Increases the likelihood of disease	No
Polygenic predisposition	Forms sensitivity of the nervous system	No directly
Female gender	Associated with higher prevalence	No
Puberty	Frequent onset period of migraine	No
Age 35-45 years	Period of high disease burden	No
Childhood	Symptoms may be shorter and more atypical	No, but diagnostics can be improved.

Sources for the table: World Health Organization, Migraine Genetics Review and American Migraine Foundation.[15] [16] [17]

Hormonal risk factors

Hormonal fluctuations are a significant risk factor for migraine in women, especially during their reproductive years. Menstrual migraine is most often associated with a period from two days before to three days after menstruation, and the UK's National Institute for Health and Care Excellence recommends documenting this association with a diary for at least two menstrual cycles. [18]

One of the key hypotheses is the premenstrual decline in estrogen levels. A 2023 review formulates this as the estrogen withdrawal hypothesis: a drop in estrogen levels before menstruation may trigger attacks in predisposed women. [19]

Hormonal risk changes throughout life. Migraines may first appear after puberty, worsen before menstruation, change during pregnancy, return after childbirth, worsen during perimenopause, and, in some women, improve after hormonal levels stabilize postmenopause. [20]

Combined hormonal contraceptives require special caution in migraine with aura. The US Centers for Disease Control and Prevention, in their 2024 guidelines, state that classification depends on the precise diagnosis of migraine and the presence of aura; for migraine without aura, combined hormonal contraceptives are classified as category 2, and for migraine with aura, they are classified as category 4, representing an unacceptable risk. [21]

Hormones aren't the only cause of attacks. Even with a clear menstrual connection, the risk of an attack is often increased by a combination of factors: declining estrogen levels, lack of sleep, stress, menstrual pain, dehydration, skipping meals, and taking medication late. [22]

Hormonal situation	How does it affect risk?	What is important to do
Menstrual window	Increases the risk of attack in some women	Keep a cycle and pain diary
Estrogen decline	May lower the seizure threshold	Plan treatment in advance
Pregnancy	For many, the course changes	New severe pain should be assessed separately
Postpartum period	Lack of sleep and hormonal decline can bring back attacks	Find a safe treatment
Perimenopause	Hormonal fluctuations can increase the frequency of attacks	Rule out new causes of headaches
Migraine with aura and estrogens	Increases vascular alertness	Discuss contraception individually

Sources for the table: UK National Institute for Health and Care Excellence, Estrogen Withdrawal Review and US Centers for Disease Control and Prevention. [23] [24] [25]

Stress, anxiety, depression and sleep

Stress is often perceived by patients as a major trigger, but it's more accurate to consider it not the sole cause, but rather an aggravator of migraine vulnerability. The American Migraine Foundation lists stress as a significant factor that can elevate a person's individual attack threshold. [26]

Anxiety and depression are significantly more common in people with migraines than in healthy individuals. The World Health Organization specifically states that anxiety and depression are significantly more common in people with migraines, and the American Migraine Foundation lists psychiatric conditions as medical factors that are important to consider when planning a treatment plan. [27] [28]

Sleep disturbance is one of the most important controllable factors. The American Migraine Foundation recommends maintaining a regular sleep schedule, as irregular sleep can lower the attack threshold; obstructive sleep apnea is also mentioned in the list of medical factors. [29]

It's important not to confuse the psychological factor with the devaluation of the illness. Migraine doesn't become "unreal" because attacks are associated with stress, anxiety, or insomnia; on the contrary, it demonstrates that the nervous system, sleep, emotions, and pain networks are closely interrelated. [30]

In practice, this means that migraine treatment should include not only medications for attacks, but also an assessment of sleep, anxiety, depression, fatigue, work schedule, and recovery breaks. For frequent migraines, these factors do not replace preventive therapy, but rather help to select it more accurately. [31]

Factor	How it can increase the risk	What helps?
Chronic stress	Lowers the seizure threshold	Recovery plan, behavioral methods
Anxiety	Increases anticipation of pain and avoidance of activity	Diagnosis and treatment of anxiety disorder
Depression	Increases disease burden and risk of chronicity	Treating depression and migraines simultaneously
Insomnia	Worsens pain regulation	A stable sleep pattern
Obstructive sleep apnea	Disrupts sleep quality and oxygen metabolism	Sleep diagnostics for snoring and drowsiness
Irregular schedule	Creates sudden load changes	Predictable sleep, food, and caffeine

Sources for table: World Health Organization, American Migraine Foundation, and International Headache Society. [32] [33] [34]

Lifestyle: Caffeine, Diet, Water, Physical Activity, and Body Weight

Lifestyle isn't a "migraine cause" per se, but it can significantly alter the frequency and severity of attacks. The American Migraine Foundation identifies sleep, exercise, nutrition, hydration, caffeine, stress, and individual triggers as important elements of migraine hygiene. [35]

Caffeine plays a dual role. While it may help relieve headaches in some people, fluctuations in caffeine levels, excess, or sudden withdrawal can increase the risk of headaches. Therefore, the American Migraine Foundation recommends paying attention to caffeine intake and avoiding sudden fluctuations. [36]

Skipping meals and not drinking enough fluids often increase vulnerability. The American Migraine Foundation recommends not skipping meals, maintaining a balanced diet, and drinking enough water throughout the day, especially if a person has a personal connection between attacks and hunger, heat, or physical activity. [37]

Obesity is considered a modifiable risk factor for migraine worsening. The American Migraine Foundation lists obesity among factors associated with migraine progression, and reviews of migraine and body weight describe an association between obesity and increased attack frequency and severity. [38] [39]

Physical activity is beneficial as part of an overall plan, but sudden and unusual exertion can trigger an attack in some people, especially in hot weather, dehydration, lack of sleep, or hunger. Therefore, the goal is not to "exercise at any cost," but to gradually increase moderate activity and avoid sudden overload. [40]

Lifestyle factor	How does it affect	A practical approach
Caffeine	Sharp vibrations can cause pain.	Keep the dose stable
Skipping meals	Hunger lowers the attack threshold	Eat regularly
Lack of water	May increase seizures and fatigue	Drink regularly
Obesity	Associated with the risk of worsening the course	Lose weight gradually and safely
Sudden load	May trigger an attack	Increase activity gradually
Heat and overheating	Increases dehydration and sensory overload	Plan for water, shade, and rest

Sources for table: American Migraine Foundation and Systematic Data on Migraine and Obesity. [41] [42]

Frequent attacks, poor treatment and drug overload

Attack frequency itself is a risk factor for worsening. The American Migraine Foundation notes that the risk of chronic migraine increases when a person experiences four or more migraine days per month, because the brain increasingly reverts to the established migraine pathway. [43]

Insufficiently effective treatment for an attack can also contribute to progression. The American Migraine Foundation notes that people without effective acute treatment and those for whom triptans are ineffective have a higher risk of developing chronic migraine; this doesn't always mean a cause-and-effect relationship, but it emphasizes the importance of prompt treatment selection. [44]

Medication overload is one of the most important modifiable risk factors. The UK National Institute for Health and Care Excellence recommends suspecting drug-induced headache if triptans, opioids, ergotamines, or combination analgesics are taken 10 or more days per month for 3 months, or if paracetamol, aspirin, or nonsteroidal anti-inflammatory drugs are taken 15 or more days per month. [45]

The danger of medication overload is that the patient may think, "The migraine has gotten worse, I need more pills," when in fact, part of the problem is already being perpetuated by overuse of medications. Therefore, the diary should record not only the days of pain, but also all the days of medication use. [46]

If attacks are frequent, prophylaxis should be considered. The International Headache Society, in its 2024 guidelines, suggests that prophylaxis be considered successful if there is a reduction in monthly migraine or moderate-to-severe headache days of at least 50%. For chronic migraine, after several prophylactic treatments, an acceptable criterion for continuation may be a reduction of at least 30% with clinical benefit. [47]

Factor	Why is it dangerous?	What to do
4 or more migraine days per month	Increases the risk of progression	Discuss prevention
15 or more days of headache per month	Chronic migraine is possible	A specialized assessment is needed
Frequent triptans or combination drugs	Risk of drug-induced pain	Count the days of admission
Frequent simple painkillers	They can also cause headaches.	Limit as per doctor's plan
Poor response to acute treatment	Increases disease burden	Revise the diagram
No diary	Hides the real frequency	Keep records for at least 8 weeks

Sources for the table: American Migraine Foundation, National Institute for Health and Care Excellence (UK) and International Headache Society.[48] [49] [50]

Vascular and reproductive risk factors

Migraine with aura requires a separate vascular evaluation because it is associated with an increased risk of ischemic stroke compared to those without migraine. This does not mean stroke is inevitable, but it does change the approach to smoking, blood pressure, hormonal contraception, and other vascular factors. [51]

The US Centers for Disease Control and Prevention indicates that in women with migraine, oral contraceptive use is associated with an approximately 3-fold increased risk of ischemic stroke compared with non-use, although many studies did not specify migraine type or contraceptive formulation.[52]

For combined hormonal contraceptives, category 2 is used for migraine without aura, and category 4 is used for migraine with aura. Therefore, any new aura or noticeable change in headache pattern while taking hormonal contraceptives requires medical evaluation. [53]

Smoking, hypertension, diabetes, lipid disorders, obesity, and age increase vascular alertness in people with migraine, especially those with aura. These factors do not always increase the frequency of migraine attacks, but they are important for overall safety and medication selection. [54]

It is especially important not to confuse migraine aura with transient ischemic attack (TIA). The UK's National Institute for Health and Care Excellence recommends further investigation for atypical aura symptoms, including motor weakness, double vision, symptoms in only one eye, impaired balance, or decreased consciousness. [55]

Factor	Why is it important?	Practical conclusion
Migraine with aura	Associated with vascular alertness	Control stroke risk factors
Smoking	Increases vascular risk	Complete refusal
High blood pressure	Increases the risk of vascular events	Regular monitoring and treatment
Combined hormonal contraception	Not recommended for aura	Select alternatives
New aura	It may not be a migraine	Need an estimate
Symptom in only 1 eye	Atypical for a normal aura	Rule out ocular and vascular causes

Sources for the table: US Centers for Disease Control and Prevention and the UK National Institute for Health and Care Excellence. [56] [57]

How to assess personal risk and reduce the likelihood of chronicity

The primary tool for assessing personal risk is a headache diary. The UK's National Institute for Health and Care Excellence recommends recording the frequency, duration, and severity of headaches, associated symptoms, all prescribed and over-the-counter medications, potential triggers, and the relationship with menstruation for at least 8 weeks. [58]

A diary helps identify not only triggers but also the risk of chronicity. If your records show an increase in pain days, an increase in medication days, attacks after sleep deprivation, frequent caffeine use, anxiety, skipping meals, and decreased performance, you need to revise your plan rather than simply adding more painkillers. [59]

The American Migraine Foundation suggests viewing migraine as a disease with an individual threshold: sleep, water, diet, caffeine, stress, medications, and comorbidities can increase or decrease the likelihood of an attack. This model is useful because it replaces the chaotic search for the "culprit" with a systematic approach to addressing multiple factors. [60]

If headaches become frequent or significantly disruptive, preventive treatment should be considered. The International Headache Society recommends assessing the effectiveness of prevention by diary records, reduction in migraine days, subjective improvement, and reduction in disease burden. [61]

Reducing risk doesn't mean the patient must monitor every detail and live in fear of an attack. The goal is to eliminate the most powerful and manageable factors: medication overload, irregular sleep, sudden fluctuations in caffeine intake, skipping meals, dehydration, untreated anxiety or depression, obstructive sleep apnea, and lack of prophylaxis for frequent migraines. [62]

What to track	Why is it important?	When to see a doctor
Days of headache	Show the risk of chronicity	As the frequency increases
Migraine days	They help solve the issue of prevention	For 4 or more days per month
Days of Medicine	Drug overload is detected	With 10-15 days of medication per month
Dream	Often associated with seizures	For insomnia, snoring, daytime sleepiness
Menstrual cycle	Reveals the hormonal window	With a repeatability of 2 out of 3 cycles
Anxiety and mood	Affect the burden of disease	For persistent anxiety or depression
Caffeine, food, water	Show controllable factors	With repeated communication

Sources for the table: National Institute for Health and Care Excellence, UK, American Migraine Foundation and International Headache Society. [63] [64] [65]

Frequently asked questions

Are migraine risk factors and triggers the same thing?
No. A risk factor increases the overall likelihood of a migraine or its worsening, while a trigger can trigger a specific attack. For example, heredity and female gender are risk factors, while lack of sleep or alcohol are possible triggers for a specific attack. [66]

Is heredity the most important risk factor for migraine?
Heredity is very important, but it is not the only one. Many people develop migraines due to a combination of genetic predisposition, hormonal factors, sleep, stress, lifestyle, and comorbidities. [67]

Why are migraines more common in women?
Female gender is associated with a higher prevalence of migraines, likely due to hormonal influences. Particularly important are estrogen fluctuations, the menstrual cycle, pregnancy, the postpartum period, and perimenopause. [68]

When can episodic migraine become chronic?
Chronic migraine is defined as 15 or more headache days per month for more than 3 months, with at least 8 days having migraine-like features. The risk increases with frequent attacks, medication overload, obesity, sleep disturbances, depression, and poor attack control. [69] [70]

How many days of medication per month is dangerous?
The UK's National Institute for Health and Care Excellence recommends caution when using triptans, opioids, ergotamines, or combination analgesics for 10 days or more per month for 3 months, and when using paracetamol, aspirin, or nonsteroidal anti-inflammatory drugs for 15 days or more per month. [71]

Could poor sleep really be a risk factor?
Yes. Regular sleep is included in basic migraine hygiene recommendations, and obstructive sleep apnea is listed among the medical factors that can influence migraines. If snoring, sleep apnea, and daytime sleepiness are present, a sleep study should be considered. [72]

Does Obesity Cause Migraines?
Obesity is not the sole cause of migraines, but it is associated with a higher risk of worsening the course and becoming chronic in some patients. Weight loss should be gradual and safe, avoiding starvation, as skipping meals can trigger attacks. [73] [74]

Should you completely eliminate coffee?
Not always. Consistency is key: sudden fluctuations in caffeine, excess, or withdrawal can be problematic, while some people tolerate a small, regular dose well. It's best to monitor individual interactions using a diary rather than a blanket ban. [75]

Is migraine with aura more dangerous than migraine without aura?
Migraine with aura requires greater vascular caution, especially in smokers, those with high blood pressure, and when choosing combined hormonal contraception. The US Centers for Disease Control and Prevention classifies combined hormonal contraceptives for migraine with aura as Category 4. [76]

How do you know when it's time to discuss prevention?
Prevention should be considered if you experience four or more migraine or headache days per month, experience significant disruption to your life, have a poor response to treatment during an attack, or frequently use medications. The effectiveness of prevention is best assessed using a diary rather than memory alone. [77] [78]

Key points from experts

Richard B. Lipton, MD, professor of neurology at Albert Einstein College of Medicine, emphasizes that the risk of migraine progression is not related to a single cause, but to a combination of attack frequency, medication use, comorbid conditions, and treatment effectiveness. [79]

Dawn Buse, PhD, is a clinical professor of neurology at Albert Einstein College of Medicine. Her research and clinical work are important for understanding the relationship of migraine to anxiety, depression, disability, and quality of life; these conditions do not “invent” pain but rather increase its burden and require separate assessment. [80]

Claire Sando, MD, Women's College Hospital Centre for Headache, University of Toronto, points out in a paper from the American Migraine Foundation that some risk factors for progression are modifiable: smoking, obesity, sleep problems, and medication overload; however, female gender, stressful life events, and adverse early experiences are less controllable. [81]

Francesca Puledda, MD, a neurologist, is the lead author of the 2024 International Headache Society guidelines for migraine preventive treatment. The practical implication of these guidelines is that prevention should be assessed by the reduction in migraine days, subjective improvement, and reduction in disability, and not just by the complete disappearance of attacks. [82]

Experts from the UK's National Institute for Health and Care Excellence. Their key contribution to the topic of risk factors is clear recommendations on headache diaries, diagnosis of chronic migraine, identification of drug-induced headache, and caution in the case of atypical aura. [83]

Final conclusions

Migraine risk factors are divided into non-modifiable and modifiable. Non-modifiable factors include heredity, age, female gender, and some hormonal sensitivity; modifiable factors include sleep, caffeine, drug overload, obesity, smoking, stress, and associated conditions. [84]

The most dangerous practical scenario is not the migraine itself, but its progression: an increase in the number of days of pain, frequent use of medications, decreased performance, anxiety in anticipation of an attack, and the transition to chronic migraine. [85]

A headache diary for at least 8 weeks is a key tool to help identify personal risk factors, relationship with menstruation, medication load, sleep, stress, caffeine, and treatment effectiveness. [86]

If attacks occur 4 or more days per month, are poorly controlled, or require frequent medication, preventative treatment should be discussed rather than simply increasing the amount of pain medication.[87][88]

Migraine with aura requires special vascular precautions: smoking cessation, blood pressure control and careful choice of hormonal contraception are particularly important to reduce long-term risks. [89]