The patient: “Annika,” a 44-year-old magazine publisher and Hawaii resident.

Why she came to see me: Annika had moved to the islands five months earlier to oversee a regional publication that she deemed “exhilarating.” But with the relocation and new, more demanding job came her first experience with migraines—severe headaches that typically impacted the left side of her head and left her so miserable she could “barely make it through the day.” She’d called in sick twice in the last two months alone—“something I’ve never done in my life,” she explained—and found only temporary relief in the Imitrex her new primary care physician had prescribed for her. Given that part of her decision to relocate to Hawaii was to live as cleanly and healthfully as possible, she wanted to not only get to the bottom of her persistent migraines, but to also treat them naturally.

How I evaluated her: Because I am a big believer that healing begins with making a personal connection, I spent a solid session with Annika discussing her life, medical history and the frequency and intensity of her migraines. She was divorced, childless by choice and had devoted much of her life to her career. In her thirties, she’d staved off mild depression with exercise, attending Spin and Zumba classes, working out with weights and hitting the treadmill up to five evenings a week. She’d always had regular, “super-timely” periods and followed a balanced diet.

And yet, as her career progressed—and as each new promotion arrived with more stress and more responsibilities—her commitment to fitness and “a mindful, flexitarian diet” began to suffer. She usually decompressed with a glass of Chianti and “gourmet eats” like prosciutto and Camembert. Naturally thin, she didn’t give much thought to these lifestyle changes until she started experiencing these acute and often debilitating headaches. While the migraines left her dizzied to the point that she couldn’t report when, precisely, they struck, she said they tended to arrive “roughly every three and a half to four weeks.” In addition to throbbing pain, she experienced nausea, fatigue, a distorted sense of smell and complications with her vision—bright spots, flashes, and peripheral disturbances that are known as “migraine aura.” At the same time, she was also experiencing symptoms that ranged from “crazy mood swings” to insomnia and occasional acne.

To rule out the possibility of a serious illness, I ordered an MRI. I also conducted a thorough neurological assessment. Based on my belief that her migraines were directly associated with her period, I also performed a full gynecological exam and ordered a 24-hour urine hormone test on the 21st day of her cycle that would allow me to assess her levels of estrogen and progesterone. Finally, I ordered a comprehensive blood panel that included an evaluation of her liver enzymes.

What my evaluation revealed: In looking at Annika’s age and symptoms, it was clear to me, even prior to the return of her lab results, that she was in perimenopause—a “transition” that occurs eight to 10 years before the ovaries stop releasing eggs (menopause).

Classically, perimenopause symptoms present as breast tenderness, weight gain, worsening premenstrual symptoms and hot flashes, but a number of women also experience the very type of headaches from which Annika was suffering—searing pain, aura and exhaustion; in short, migraines. This is due to the hormone fluctuations that transpire during this era, in which progesterone levels are lower than estrogen…something that was confirmed in the hormone test I ordered. (Women with a history of depression and chronic stress are also more likely to experience perimenopause migraines.)

Luckily, Annika did not test positive for a serious illness, and her gynecological exam was clear. While certainly uncomfortable for Annika, her diagnosis was ultimately excellent news: Cyclical migraines are eminently treatable.

How I addressed her problem: To remedy Annika’s migraines from a holistic perspective, we began with diet and exercise. First, I recommended that she nix common migraine food triggers not just during her period but throughout the entire month:
* Foods containing tyramines (which may lead to chemical changes in the brain and cause migraines) including aged cheeses, red wine, cured meats, and soy. Gluten can also be a trigger.
*Artificial sweeteners.
* Anything containing MSG. This troublesome ingredient goes by many monikers in ingredient lists, so read labels carefully.  

Instead, I suggested she fill her plate with fatty fish (salmon, mackerel, sardines, etc.), complex carbs like brown rice, and plenty of green vegetables with a particular focus on cruciferous vegetables (broccoli, cauliflower, Brussels sprouts, kale, etc.), which bolster “friendly” estrogen.

I also urged her to incorporate ginger into her diet. This potent herb not only aids in the nausea that often accompanies migraines but also has the capacity to block prostaglandins—neurotransmitters that play a role in inflammation and may be at the root of pain (head and otherwise).

Further, I encouraged Annika to reprioritize fitness. Whether gentle or vigorous, exercise has the ability to naturally ease stress—a contributing factor to hormone-related migraines. That’s because stress often results in altered cortisol levels, which upsets hormone balance. I let her know that a combination of strength training, cardio, and grounding exercises (such as yoga) best support hormone balance, in part by boosting dopamine, serotonin and estrogen.

I also urged Annika to address her “life fitness” by creating—and adhering to—a more balanced lifestyle. Pushing herself nonstop at work and making little time for fun and play was taking a toll on her adrenal health—and this, too, can intensify hormone fluctuations and cause migraines.

To boost her progesterone, I suggested she supplement her diet with Chaste Tree Berry, a phyto-progesterone (also known as Vitex) that organically raises progesterone, diminishes premenstrual and perimenopause symptoms, and encourages overall hormone balance.

Given that Annika’s comprehensive panel suggested she had a sluggish liver, I encouraged her to work towards optimizing this organ’s health. Unbeknownst to many, the liver is critical to hormone balance and function—it processes and breaks down hormones including estrogen. Indeed, in Traditional Chinese medicine, migraines are believed to be due to a “congested” liver in which Qi isn’t flowing smoothly, thus generating head pain. Supporting the liver, then, is paramount to successfully treating migraines. To that end, I recommended acupuncture and the supplement Xiao Yao Wan. Otherwise known as “Free and Easy Wanderer,” the combination of herbs, which includes bupleurum (an herb), poria (a mushroom), peppermint, and white peony root, has long been used to manage liver Qi stagnation—and to shield the body against stress-related biochemistry changes.

To this I added two daily doses of 200 mg of riboflavin (or Vitamin B2), which has been shown to increase nitric oxide at the blood vessel wall, thereby preventing the vasoconstriction that can cause migraines. Finally, in addition to the green vegetables I urged her to become best friends with, I encouraged her to take 400 mg of magnesium per day. As the American Migraine Foundation reports, this magic mineral has migraine-preventative (and relieving) properties that can be especially valuable for those who also suffer from migraine with aura.

The patient’s progress: Within two months of Annika’s lifestyle changes and supplementation, she returned to my office looking far less fatigued and disturbed, and with a clearer, more radiant complexion—a common benefit of eating Omega 3-rich fatty fish and those green veggies I’d prescribed. Her enthusiasm for her position at the magazine was “as strong as ever” but she’d found some equilibrium with work and play by joining a local beach volleyball team and “discovering Tai Chi.” Most importantly, she was migraine-free during the end of her cycle and throughout the month—which, to her, felt like the biggest and best promotion she’d ever received.

To learn more, visit Dr. Laurie Steelsmith’s website,, or click her to read her most recent book, Growing Younger Every Day: The Three Essential Steps for Creating Youthful Hormone Balance at Any Age.