Jealousy in women with migraine: a cross-sectional case-control study

Sex hormones have a major influence on migraine, appearing from a three times higher migraine prevalence in premenopausal women compared to men, an increase in attack frequency during menopausal transition, and a postmenopausal decrease of symptoms [1‐3]. Furthermore, the fluctuation of estrogen prior to menstruation is evidently linked to an increased susceptibility to an upcoming attack [4]. Two subtypes of migraine with menstruation-associated attacks exist: pure menstrual migraine (PMM) and menstrually-related migraine (MRM). In MRM, attacks occur additionally at other times of the cycle. For research purposes, PMM and MRM are often taken together and defined as menstrual migraine (MM) [5]. Although the exact pathophysiological underlying mechanism remains unclear, previous research has suggested that fluctuations in estrogen levels, possibly the rate of decrease in estrogen, may affect the susceptibility to migraine attacks in women and/or higher estrogen levels may be implicated in both sexes [2, 6‐9].

Problems within a romantic relationship, such as jealousy, divorce, and bereavement after the suicide of a partner potentially have a large impact on quality of life [10, 11]. Knowledge on potential associations between relationship problems and disabling chronic diseases, such as migraine, may increase our understanding, reduce stigma, and improve disease outcomes. Relationship jealousy can be defined as thoughts, emotions, or behaviors that occur as a result of the perceived threat of losing a partner to an actual or imagined rival [12]. In the fertile phase, when estrogen levels are high, women tend to report higher jealousy levels compared to other times of the menstrual cycle [13]. Furthermore, jealousy seems to be affected by the use of combined oral contraceptives. Especially using formulations with higher doses of ethinyl estradiol are associated with significantly higher jealousy scores [13‐15]. These findings indicate that estrogen plays a role in jealousy within a romantic relationship, but the exact underlying mechanism is unknown.

That biological factors may affect mental health has been illustrated by previous research concluding that alterations in prolactin and thyroid hormone levels are associated with suicide attempts in psychiatric patients [16].

We hypothesized that women with migraine, especially those fulfilling the criteria of MM, would have higher jealousy levels compared to women with non-menstrual migraine (non-MM) and premenopausal controls due to a corresponding provoking effect of estrogen in migraine and jealousy. Secondarily, we hypothesized that postmenopausal migraineurs and controls report low and similar jealousy levels due to stabilization of sex hormones [3, 17]. Lastly, we investigated the effect of using combined oral contraceptives on jealousy, aiming to replicate previous results on this topic.

Premenopausal women with migraine in a relationship have significantly higher jealousy scores than controls in this study. This is independent from whether they experience menstrually-related attacks and the effect disappears after menopause. Our hypothesis is that this association between migraine and increased jealousy is due to the effect of estrogen. Previous research showed estrogen levels to be higher in women with MM compared to controls during most phases of the menstrual cycle, and with only small differences between MM and non-MM patients [7, 8]. As estrogen levels will be low in the postmenopausal stage of life we expected that difference in jealousy levels would diminish and indeed we did not find differences when comparing postmenopausal female migraine patients with controls supporting our hypothesis. Interestingly, we did not find a significant difference in jealously between patients with menstrually-related attacks (MM) and those without menstrually-related attacks (non-MM). We imagine that there might be one important explanation for this, namely the inaccuracy of non-diary self-reported MM or non-MM diagnosis. In a recent study, we asked 104 female migraine patients whether their attacks were associated with the menstruation and then collected prospective e-diaries. In this study, we showed women’s self-reported diagnoses had a positive predictive value of 65% and negative predictive value of 50%. Sensitivity was 80% and specificity 33% [22]. Accurate MM diagnoses are difficult to obtain even when prospective diaries are collected. Previous research has shown that current ICHD-3 diagnostic criteria for MM reached maximum sensitivity only for three menstrual cycles, although specificity increased with more cycles of data collection [23]. Thus, accuracy of self-reported menstrual-related migraine diagnosis is poor in female migraine patients and we suggest to reconsider the ICHD-3 criteria for menstrual migraine where no prospective diary data is required anymore to confirm MM.

Are there alternative explanations for our findings? The effect of a disabling chronic disease on the quality of life might explain the higher jealousy response within romantic relationships in female migraine patients. The most recent Global Burden of Disease study ranked migraine as the second most disabling disease worldwide [24]. Previous studies showed that migraine patients scored lower on health-related quality of life domains than controls, such as social functioning and mental health [25, 26]. Female migraine patients might have less social interaction compared to their partners, both during a migraine attack due to severe headache and disabling associated symptoms, but also outside migraine attacks due to an adjusted lifestyle trying to prevent migraine attacks. One could imagine that a disbalance in social interactions in a romantic relationship may induce jealousy towards a partner. Studying the association between other disabling chronic diseases and jealousy within romantic relationships may be of interest in this light. Although postmenopausal women with migraine are limited in social activities, their jealousy response is comparable to that of postmenopausal controls, suggesting that impaired social functioning only partially contributes to the difference in jealousy between younger migraine patients and controls. Several population-based studies have analysed the prevalence of disabling pain disorders and associated risk factors. Separated or divorced status is consistently associated with an increased risk of (chronic) pain in women [27‐29]. Additionally, separation and divorce have been suggested to be a risk factor for worsening outcomes in pain disorders with persisting pain [30]. This knowledge might be helpful in understanding the potential adverse effects of migraine on the relationships of patients, such as jealousy and potentially divorce.

A recent meta-analysis on personality of migraine patients has shown higher risk for neuroticism and harm avoidance, and for low self-directedness and extraversion in migraineurs [31], which hypothetically may be involved in more pronounced reactive and anxious jealousy scores than preventive scores for MM patients.

Women using combined oral contraceptives reported higher jealousy compared to non-using women with a regular menstrual cycle, which is congruent with previous studies [13, 20]. With this, our study contributes to the existing literature by using a different study population and adjusting for relevant covariates, which limits potential confounders and increases the validity. Participants in our study were older and had a longer relationship duration compared to participants in other studies, who were students with a mean age of 22 years and a mean relationship duration of 1 year [13, 20]. The higher jealousy levels in women using combined oral contraceptives might be caused by an effect of estrogen, which is suggested to influence jealous behavior [14, 15]. Progesterone dose in combined oral contraceptives is shown to be unrelated to reported jealousy, but combined oral contraceptives with higher doses of ethinyl estradiol are associated with higher jealousy compared with formulations with lower ethinyl estradiol doses [14, 15].

This study has a number of strengths. A large number of participants from the reliable LUMINA cohort were recruited. Furthermore, a validated jealousy scale was used, with a Cronbach’s alpha of 0.843 indicating a very good internal consistency. However, some limitations of our study should be mentioned. Firstly, a considerable part of invited women were classified as non-responders. The non-response rate could partially be explained by women who were not eligible for participation, e.g. as they had no romantic partnership at the time of the study but refrained from informing the investigators. Secondly, as indicated the MM and non-MM diagnoses in this study were not based on diary data as this is not a requirement anymore in the ICHD-3 classification. In addition, the phase of the menstrual cycle at the time of completing the questionnaire is unknown. In a prior study, higher jealousy levels were found in the fertile phase compared to the non-fertile phase of the menstrual cycle. However, this effect became marginally significant when comparing the menstrual cycle phases in partnered women [13]. Since we included only partnered women, this is thus thought to be of less importance for our results. Additionally, since the percentage of women with a regular menstrual cycle in the MM and control group is comparable (41% vs. 42% respectively), the amount of women in the fertile and non-fertile phase is expected to be equally distributed in these groups.

Our study is the first to show that young migraine women are more jealous within a romantic partnership than non-migraine women. We suggest estrogen to play an important role in this relationship. Future research is needed on establishing the role of estrogen in women with migraine as this may provide important treatment options for this incapacitating disorder. We encourage physicians treating patients with migraine to pay attention to aspects of social functioning.