Headaches and family planning: insights from a Japanese school-based survey

Abstract

Objective

To investigate the effect of headaches on women’s pregnancy plans and fertility intentions.

Methods

We prospectively performed a school-based online survey for students’ parents in Suwa city, Japan, in 2023. We asked their age, sex, the number of children, the presence of headache attacks, the use of acute and prophylactic medications, monthly headache days (MHD), monthly acute medication intake days (AMD), headache impact test-6 (HIT-6), and whether or not headaches worsen during menstruation. We also examined headache’s effect on pregnancy plans and asked about how headaches would affect pregnancy, the ability to raise a child, and the child’s health.Of 5558 students' households, we retrieved 1142 (20.1%) answers, and 717 (12.9%) responses from parents with headaches.

Results

Of 5558 students’ households, we retrieved 1142 (20.1%) answers, and 717 (12.9%) responses from parents with headaches were finally analyzed. The median (first quartile-third quartile) age was 43 (37–46) years, and 653 (91.1%) were female. Median MHD, AMD, and HIT-6 were 3 (1–6), 3 (1.5-6), and 62 (58–65), respectively. Twenty-four (3.3%) used prophylactic medications and 562 (78.4%) used acute medications for headache attacks. The median number of children was 2 (1–2). Avoid pregnancy group consisted of 39/717 (5.4%) respondents. They were younger (median 39 years; first quartile-third quartile 33–42 years), with more respondents with headaches worsening during menstruation (28/35; 80.0%), with acute medication use (36/39; 92.3%), and had more MHD (5; 3–10), more AMD (5; 2–11), and high HIT-6 score (66; 60–67), compared to the no impact group. They tended to think that headaches would be worse during pregnancy (16/39; 41.0%) and that headaches negatively affect pregnancy (28/39; 71.8%), raising a child (20/39; 51.3%), and the child’s development (31/39; 79.5%) and risk of having a headache (28/39; 71.8%) compared to the no impact group.

Conclusions

Some of the respondents avoided pregnancy because of their headaches. Those in avoid pregnancy group had severe headaches and felt that headaches negatively affected family planning.

Supplementary Information

The online version contains supplementary material available at 10.1186/s10194-025-02102-3.

Study highlights

1. We prospectively performed a school-based online survey of 5558 students' households and retrieved 717 (12.9%) responses from parents with headaches.

2. Of those, 678/717 (94.6%) responded as no impact group on pregnancy plan, and 39/717 (5.4%) were respondents with avoiding pregnancy.

3. Avoid pregnancy group was younger, with more respondents with headaches worsening during menstruation, and had more frequency and severity of headaches.

Supplementary Information

The online version contains supplementary material available at 10.1186/s10194-025-02102-3.

Introduction

Japan’s declining birthrate and aged population are extremely important issues. The number of births in Japan was around 1 million in 2015, but it has since fallen at a rate of −3.5% per year, decreasing to 810,000 by 2021. The factors contributing to this decline are categorized into population, marriage rates, and the rate of births among married women. The decline in the rate of births to married women, a fertility intention in other words, has mainly led to the acceleration of the decline in the birth rate. One of the main reasons for the declining fertility intention among the younger Japanese generation is the deterioration of the economic and employment environment [1]. The declining birth rate in Japan is significantly influenced by the societal advancement of women, which has outpaced the implementation of systems to support working mothers. For instance, there is a shortage of daycare centers, low salaries, and long work. Additionally, the high cost of raising children often leads women to postpone pregnancy until they feel financially secure, a trend that is expected to grow [2]. When women are unable to conceive or have children due to social or economic barriers rather than biological ones, this is referred to as “social infertility” —a challenge that severely impacts both individual women and the overall population dynamics.

Headache is one of the most prevalent neurological disorders, and it is a common public health problem with its severe burden worldwide, negatively affecting the years lived with disability [3]. The International Classification of Headache Disorders, 3rd edition (ICHD-3) [4], describes migraine, tension-type headache (TTH), and trigeminal autonomic cephalalgias (TACs) as key primary headache disorders. In Japan, the prevalence of migraine ranges from 4.3 to 8.4% [5], with 29.8–74.2% of individuals with migraine reporting substantial disruptions to daily activities [6]. Tension-type headaches affect approximately 15–20% of the population, with 22.4–29.2% of those impacted experiencing reduced productivity [7]. Additionally, TACs are diagnosed in about 3.5% of patients attending headache clinics [8]. Effective management of headache disorders is crucial, including acute and prophylactic medication with accurate diagnosis in accordance with ICHD-3 criteria [9].

Headache disorders are common in women [5], and there is also debate about their relationship to events that are specific to women. Menstruation, pregnancy, and menopause are closely linked to especially migraine due to changes in hormonal balance, particularly involving estrogen and progesterone [10]. During menstruation, the rapid drop in estrogen levels is a known trigger for migraine [11], often referred to as “menstrual-related migraine.” During pregnancy, estrogen levels remain consistently high, which leads to a reduction in the frequency and severity of migraine for many women [12]. Conversely, during menopause, hormonal fluctuations can worsen migraine for some individuals. However, after menopause, as hormone levels stabilize, migraine may improve [10]. These hormonal changes play a significant role in influencing migraine patterns, and there is an inseparable relationship between women’s life events and headaches.

Two major headaches, both migraine and tension-type headaches, have huge economic and social impacts [7, 13, 14]. Headache significantly impacts a patient’s quality of life during an attack and between attacks [15]. Headache burden is linked to anxiety regarding potential future headache episodes and worries about how these attacks might negatively influence upcoming plans or activities [16, 17].

In this context, we hypothesized that migraine and headaches affect birth planning because headache disorders are diseases that cause a social and economic burden [14, 18]. Previously, one migraine patient-based report from headache-specialized clinics in the United States [19], one web-based survey report from migraine patients in the United States [20], and a cross-sectional survey on migraine headache patients in Europe [21] revealed that 1 to 20% of migraine patients reported that they avoided pregnancy because of migraine. However, there have been no reports on the relationship between headaches and pregnancy planning from Japan, so there is a lack of data regarding the association between family planning and headaches in the Japanese population. Therefore, we conducted a school-based online survey to reveal the headache’s impact on fertility intention in Japan.

Materials and methods

Online questionnaire procedure

We performed this survey prospectively, starting from August to December 2023. This campaign was cooperatively conducted in Suwa, Nagano, Japan, by the Japanese Red Cross Suwa Hospital, two high schools in Suwa, and Suwa City Servant Service. The overall population of Suwa was 47,594, the working-age population was 26,461 (55.6%), and the retirement-aged population was 14,901 (31.3%). The number of elementary, junior high, and high school students was 5,558 (11.1%). Primary and secondary industries account for 5.3% and 36.4% of the city’s population. Compared to Japan as a whole, secondary industries make up a significant share of the city’s workforce. There is only one general hospital with a headache-specialized outpatient and one headache specialist.

During the coronavirus disease 2019 pandemic, elementary, junior high, and high schools in Suwa occasionally had to close. Starting in 2021, each student was provided with a loaned tablet, allowing for interactive remote learning when appropriate. The students’ parents were asked to answer the questionnaire through Google Forms using tablet terminals or their own smartphones. The sex of the parent’s response was not specified, but one parent was asked to respond. There were no missing data in the valid responses.

Questionnaire items

We asked the parents’ age, biological sex, the number of children, the presence of headache attacks in these three months apart from infection like a cold or head injury, acute and prophylactic medications used in the past three months, monthly headache days (MHD), monthly acute medication intake days (AMD), headache impact test-6 (HIT-6), and whether or not headaches worsen during menstruation. We asked this because we hypothesized that people whose headaches worsen during menstruation also think that headaches affect pregnancy. Acute medication included non-steroidal anti-inflammatory drugs, triptans, and lasmiditan. Prophylactic medication included lomerizine, propranolol, valproic acid, amitriptyline, and calcitonin gene-related peptide-related drugs.

We asked further questions of those who answered that they had headache attacks. We examined headache’s effect on pregnancy plans by using three alternative answers to the question, “Have headaches impacted your plans for pregnancy?” The answers consisted of “avoid pregnancy,” “no impact,” and “increased desire to get pregnant.” We examined the reasons why headaches would affect pregnancy using six individual questions about how headaches might affect pregnancy, the ability to raise a child, and the child’s health: The six individual questions included; Q1: My headaches would be worse during or just after pregnancy. Q2: Disability caused by headaches makes pregnancy very difficult. Q3: Disability caused by headaches makes raising a child very difficult. Q4: The headache medications I take would negatively affect my child’s development. Q5: Headache would cause my baby to have abnormalities at birth. Q6: I would pass on genes to my baby that increase the risk of my baby having headaches. These questions were the same as in the previous report [19], and the answers consisted of yes/no answers.

Then, they saw a 10-minute-long e-learning video by a headache physician through the online survey, which explained six crucial topics from the Clinical Practice Guideline for Headache Disorders 2021 [9]. Topic 1: The economic loss caused by headaches, including interference with work, schoolwork, and household chores, has become a social problem (economic loss by headache). Topic 2: The economic loss due to reduced performance in studies and work caused by headaches (presenteeism) is greater than the economic loss due to missed school or work caused by headaches (absenteeism) (presenteeism > absenteeism). Topic 3: Headache is a symptom; it can be caused by any number of diseases (e.g., migraine, tension-type headache) (Headache is a symptom). Topic 4: If you have migraine attacks more than twice a month, if you have strong headaches more than 3 days a month, or if you take painkillers more than 10 days a month, you should consult doctors (need to consult doctors). Topic 5: There are two important headache treatments: (1) acute and (2) prophylactic medications (acute and prophylactic medication). Topic 6: There is a “medication-overuse headache (MOH),” in which the headache returns and worsens by taking painkillers more than 10 days a month (presence of MOH). The six topics were the same as those in the previous awareness campaign in Itoigawa, Japan, and the survey procedure was also same [22]. We finally asked them about their awareness and understanding of these six topics, and respondents answered as “I have already been aware,” “I did not know, but I learned,” and “I did not know, and I disagree.”

Statistical analysis

Descriptive statistics are presented as median (first quiartile-third quiartile) or number (percentage). Patients were divided into two groups: the avoid pregnancy group, which chose “avoid pregnancy,” and the no impact group, which chose “no impact” or “increased desire to get pregnant.” We compare the main characteristics between these two groups. This is the primary analysis of these datasets, and the nature of this analysis was preplanned. A chi-squared and Fisher’s exact tests were performed to compare the proportions, and the Mann-Whitney U test was performed to compare the numerical values. A priori statistical power calculation was not conducted. The target enrollment was based on the desire to sample as many residential individuals in the population as possible. A two-tailed p < 0.05 was defined as statistically significant. We used SPSS software version 29.0.0 (IBM Corp., Armonk, New York, USA), Python 3.9.0, Matplotlib 3.5.1, and seaborn 0.13.2.

Ethical aspects

The Japanese Red Cross Suwa Hospital Ethics Committee approved this study (approval number: R5-1). The questionnaire was anonymous and did not contain any personally identifiable information. The purpose of the study was explained to the participants in writing and handed to them as well as shown in the online survey form. They were asked to complete the survey sheet if they could participate in the study. If they were unable or did not want to participate, they were asked to submit a blank sheet, thus providing an opportunity for non-participation. We never forced the respondents to participate in this survey; we only invited them to participate of their own free will. All methods were carried out under relevant guidelines and regulations (Declaration of Helsinki). This study deleted all personal patient information from the database to protect patient privacy. The requirement for written informed consent was waived.

Results

Of 5558 students’ households, we retrieved 1142 (20.1%) answers. Seven were with the declaration of non-participation, and 418 were from those without headaches. Finally, 717 (12.9%) responses from parents with headaches were analyzed. The median (first quartile-third quartile) age was 43 (37–46) years, and 653 (91.1%) were female. Median MHD, AMD, and HIT-6 were 3 (1–6), 3 (1.5-6), and 62 (58–65), respectively. Twenty-four (3.3%) used prophylactic medications and 562 (78.4%) used acute medications for headache attacks. The median number of children was 2 (1–2).

Of those, 678 (94.6%) responded as no impact group on pregnancy plan, including three respondents with “increased desire to get pregnant by headaches.” Avoid pregnancy group consisted of 39 (5.4%) respondents. They were younger, with more respondents with headaches worsening during menstruation, with acute medication use, and had more MHD, more AMD, and high HIT-6 score, compared to the no impact group (Fig. 1 and Supplementary Fig. 1 A). The proportions of the answer “yes” against Q1 to Q6 were higher in avoid pregnancy group, suggesting headache negatively affects pregnancy and child’s development: The proportions of answer “yes” among no impact group vs. avoid pregnancy group were 23.6% vs. 41.0% for Q1, 19.2% vs. 71.8% for Q2, 16.7% vs. 51.3% for Q3, 46.5% vs. 79.5% for Q4, 10.5% vs. 35.9% for Q5, and 57.8% vs. 71.8% for Q6, respectively (Table 1 and Fig. 2). (Q1: My headaches would be worse during or just after pregnancy. Q2: Disability caused by headaches makes pregnancy very difficult. Q3: Disability caused by headaches makes raising a child very difficult. Q4: The headache medications I take would negatively affect my child’s development. Q5: Headache would cause my baby to have abnormalities at birth. Q6: I would pass on genes to my baby that increase the risk of my baby having headaches).

Fig. 1.

MHD, AMD, and HIT-6 for each group. MHD, AMD, and HIT-6 score are severe in avoid pregnancy group compared to no impact group. ***; p < 0.001 by the Mann-Whitney U test

Table 1.

Clinical characteristics

	Total	IQR or %	No impact group	IQR or %	Avoid pregnancy group	IQR or %	p values
Number	717	100%	678	94.6%	39	5.4%
Elementary school	502	70.0%	472	69.6%	30	76.9%
Junior high school	142	19.8%	133	19.6%	9	23.1%
High school	73	10.2%	73	10.8%	0	0%
Age	43	37–46	43	37–46	39	33–42	< 0.001
Sex; Female	653	91.1%	618	91.2%	35	89.7%	0.764
MHD	3	1–6	3	1–6	5	3–10	< 0.001
Use of acute medication	562	78.4%	526	77.6%	36	92.3%	0.030
AMD	3	1.5-6	2	1.5-6	5	2–11	< 0.001
Use of prophylactic medication	24	3.3%	24	3.5%	0	0.0%	0.232
HIT-6	62	58–65	60	55–64	66	60–67	< 0.001
Number of children	2	1–2	2	1–2	2	1–2	0.147
Headaches worsen during menstruation; yes	350/653	53.6%	322/618	52.1%	28/35	80.0%	0.001
Q1: My headaches would be worse during or just after pregnancy; yes	176	24.5%	160	23.6%	16	41.0%	0.001
Q2: Disability caused by headache makes pregnancy very difficult; yes	158	22.0%	130	19.2%	28	71.8%	0.013
Q3: Disability caused by headache makes raising a child very difficult; yes	133	18.5%	113	16.7%	20	51.3%	< 0.001
Q4: The headache medications I take would negatively affect my child’s development; yes	346	48.3%	315	46.5%	31	79.5%	< 0.001
Q5: Headache would cause my baby to have abnormalities at birth; yes	85	11.9%	71	10.5%	14	35.9%	< 0.001
Q6: I would pass on genes to my baby that increase the risk of my baby having headache; yes	420	58.6%	392	57.8%	28	71.8%	0.018

The values are actual numbers or median. The complete description is provided in Supplementary Table 1

Abbreviations: AMD Acute medication intake days, HIT-6 Headache impact test-6, IQR Interquartile range, MHD Monthly headache days

Fig. 2.

The proportions of those whose headaches worsened during menstruation, and those who responded with “yes” to Q1 to Q6 were high in avoid pregnancy group. (Q1: My headaches would be worse during or just after pregnancy. Q2: Disability caused by headaches makes pregnancy very difficult. Q3: Disability caused by headaches makes raising a child very difficult. Q4: The headache medications I take would negatively affect my child’s development. Q5: Headache would cause my baby to have abnormalities at birth. Q6: I would pass on genes to my baby that increase the risk of my baby having headaches)

MHD, AMD, and HIT-6 scores were compared for each answer to the question. Those who agreed that their headaches worsened during menstruation (Supplementary Fig. 1B) and those who agreed with Q1-Q5 had more MHD, AMD, and higher HIT-6 scores than those who disagreed (Supplementary Fig. 1C-1G). Those who agreed with Q6 had more AMD and higher HIT-6 scores than those who disagreed (Supplementary Fig. 1H).

About the awareness survey on headache clinical practice, those who disagreed with topics 1–3 (Topic 1; economic loss by headache, Topic 2; presenteeism > absenteeism, Topic 3; headache is a symptom) despite the e-learning are more in avoid pregnancy group than those in no impact group (Fig. 3A and C). However, the proportion of answers was not different in topic 4 (need to consult doctors) (Fig. 3D). Conversely, those who learned topics 5 (acute and prophylactic medication) and 6 (presence of MOH) after the e-learning were more in avoid pregnancy group than those in no impact group (Fig. 3E and F). The actual numbers and percentages are shown in Supplementary Table1.

Fig. 3.

Awareness survey results. About the awareness survey on headache clinical practice, those who disagreed with topics 1–3 (Topic 1; economic loss by headache, Topic 2; presenteeism > absenteeism, Topic 3; headache is a symptom) despite the e-learning are more in avoid pregnancy group than those in no impact group (A-C). However, the proportion of answers was not different in topic 4 (need to consult doctors) (D). Conversely, those who learned topics 5 (acute and prophylactic medication) and 6 (presence of MOH) after the e-learning were more in avoid pregnancy group than those in no impact group (E-F) ▲: more than expected frequency by the chi-square test. ▽: less than expected frequency by the chi-square test

When the results were analyzed separately for females and males, the results for females did not change compared to the whole: Those of female in the avoid pregnancy group were younger, with more respondents with headaches worsening during menstruation, with acute medication use, and had more MHD, more AMD, and high HIT-6 score, compared to the no impact group (Supplementary Table 2). Those of male in the avoid pregnancy group were younger, with more respondents with acute medication use, and had more MHD, more AMD, and high HIT-6 score, compared to the no impact group. The trends for males are the same as those for females in terms of age, MHD, HIT-6 score, AMD, and proportion of agreement with Q1-Q3 (Supplementary Table 3).

Discussion

Through the school-based online survey for parents with headaches, 678/717 (94.6%) responded as no impact group on pregnancy plan, but 39/717 (5.4%) were respondents with avoiding pregnancy. Avoid pregnancy group was younger, with more respondents with headaches worsening during menstruation, and had more MHD, more AMD, and high HIT-6 score, compared to the no impact group. The avoid pregnancy group showed higher proportions of “yes” responses to Q1 through Q6, indicating that they thought headaches may have a negative impact on pregnancy and child development. About the awareness survey on headache clinical practice, those in avoid pregnancy group tended to disagree with the topics with social disadvantages (Topic 1 to Topic 3). This is the first report on the relationship between headaches and pregnancy planning in Japanese students’ parents.

Previous reports on migraine and pregnancy planning

Ishii et al. [19] analyzed data from 607 female migraine patients in the American Registry for Migraine Research. Among them, 19.9% avoided pregnancy, citing concerns about worsening migraine (72.5%), pregnancy difficulties (68.3%), and potential negative impacts on child development (76.0%). These patients were younger, had fewer children, and higher rates of chronic migraine, menstrual migraine, and depression than those unaffected by migraine in pregnancy planning. The study emphasized educating women on migraine and pregnancy.

Buse et al. [20] examined data from the Chronic Migraine Epidemiology and Outcomes (CaMEO) Study with about 12,000 respondents. Chronic migraine (CM) patients had fewer children (1.5 vs. 1.7) and were three times more likely to avoid pregnancy than episodic migraine (EM) patients. Of parents, 38.6% believed they would parent better without migraine, with CM patients expressing this sentiment more often (64.8% vs. 35.7%). The study highlighted migraine’s impact on careers, finances, relationships, and family planning.

Lampl et al. [21] using the Eurolight dataset, found 17.6% of 2956 migraine patients reported relationship difficulties, with higher rates among women (19.7% vs. 12.8%). Around 1% avoided parenthood due to migraine. They suggested developing tools to assess migraine’s interictal and cumulative burdens on life aspects like careers, finances, and relationships.

Similar to these previous studies, our research has shown that 39/717 (5.4%) with headaches (not migraine) responded as avoided pregnancy and that those in avoid pregnancy group were younger, with more respondents with headaches worsening during menstruation, and had more MHD, more AMD, and high HIT-6 score. They also thought headaches and headache medicine affect pregnancy, children’s birth, and development. In terms of our novelty, the level of understanding was different depending on the topics when people who avoid such pregnancies and those who do not were given knowledge about headaches. The survey methods were different in the four studies, and our study did not use migraine diagnosis. In addition, in Japan, children are sometimes conceived by accident as about 20%, so it is not always a planned pregnancy. Therefore, the interpretation needs caution, but headache and migraine can somehow negatively affect infertile desire and pregnancy planning with negative thoughts and stigma.

Headache stigma and burden

Many individuals with migraine face psychological challenges, particularly stigma [23], which can lead to discrimination, social devaluation, and workplace difficulties [24]. This stigma often stems from misconceptions that migraine is “just a headache [25],” influencing individuals to downplay their condition or avoid seeking care [14]. The OVERCOME (Japan) study revealed that 43.4% of those meeting migraine criteria were undiagnosed, and nearly half had never sought treatment. Hesitancy in seeking care, reported by 36.5%, was commonly due to fears of not being taken seriously or underestimating the severity of their condition [6].

About the awareness survey on headache clinical practice in our study, those in avoid pregnancy group tended to disagree with the topics: (1) The economic loss caused by headaches, including interference with work, schoolwork, and household chores, has become a social problem; (2) The economic loss due to reduced performance in studies and work caused by headaches (presenteeism) is greater than the economic loss due to missed school or work caused by headaches (absenteeism), and (3) Headache is a symptom; it can be caused by any number of diseases (e.g., migraine, tension-type headache). Also, those in avoid pregnancy group had more MHD and higher HIT-6 scores. They had a high level of disability due to severe headaches, and they may be becoming unable to accept not only the actual disadvantages they have experienced, but also the socioeconomic indirect losses caused by headaches. These are likely to be internalized stigmas [26] they developed from their past experiences. It will be necessary to continue to raise awareness of correct knowledge about headaches so that headache patients consult doctors in their early stages and before internal stigma is formed.

These findings highlight an urgent need for targeted educational interventions to improve awareness and understanding of headache management and its implications on pregnancy. Such interventions could include school-based programs [22], public health campaigns [27], smartphone apps [28], and digital e-learning tools [22, 29] aimed at both patients and healthcare providers. By emphasizing the availability of effective headache treatments during pregnancy and addressing misconceptions about medication safety, these efforts could empower individuals to make more informed decisions. Moreover, public health initiatives must actively challenge and reduce this stigma by framing headaches as a serious neurological disorder rather than a minor inconvenience. This could involve collaboration with media outlets to disseminate accurate information and with employers to foster supportive workplace environments [13, 30]. Addressing internalized stigma, particularly among individuals who avoid pregnancy due to severe headaches, requires accessible and empathetic healthcare services that provide both medical and psychological support, such as online telemedicine [31, 32] and patient association [33].

Migraine and pregnancy

Our results suggested that headaches can negatively affect fertility intention in some patients. We also showed that some patients with headaches are worried about the impact of headache and headache treatment itself on pregnancy and the fetus. There is a need to raise awareness and to provide treatment based on more evidence-based knowledge of headaches and migraine during pregnancy. Here, we focus on migraine, which is common among headaches and can interfere with daily life, and consider their relationship to pregnancy.

Migraine severity usually improves in 55–90% of females during pregnancy. This may be because estrogen and endogenous opioids rise during pregnancy, raising the pain threshold [12]. However, some of the pregnant females continue to suffer from migraine attacks, and 7% experience a first-onset migraine attack during pregnancy [34]. Several medications have been evaluated for their safety and efficacy during pregnancy, with varying evidence supporting their use. Acetaminophen is the preferred initial option. Non-steroidal anti-inflammatory drugs (NSAIDs) can be used during early pregnancy, but they may carry a potential risk of miscarriage if taken near the time of conception. Additionally, NSAIDs are not recommended in the third trimester due to the heightened risk of premature closure of the ductus arteriosus [12]. Triptans, particularly sumatriptan, are now considered safe during pregnancy [35]. It is unclear whether gepants and ditans are safe for pregnancy and breastfeeding. As prophylactic medications, propranolol [36] and amitriptyline [37] can be used.

Monoclonal antibodies targeting calcitonin gene-related peptide (CGRP-mAbs), the first targeted preventive migraine treatments, are used for effective treatment for migraine prevention, and they mitigate the burden of headaches [38]. Therefore, if CGRP-mAbs can be safely used during pregnancy, they may potentially improve the fertility intention among migraine patients. However, CGRP-mAbs have undemonstrated safety during pregnancy. With an elimination half-life of 27–31 days, they take nearly five months to clear the body fully. Consequently, their use during pregnancy is not approved by the US Food and Drug Administration or European Medicines Agency. Recent reports describe six cases who had CGRP-mAbs during the periconceptional period. One of them experienced miscarriage, and another had severe perinatal asphyxia. However, the direct relationship between these events and CGRP-mAbs is unknown [39]. Bussiere et al. assessed erenumab’s safety in pregnant cynomolgus monkeys, finding no effects on body weight, gestation, or pregnancy outcomes, with fetal losses and preterm births similar to controls [40]. CGRP-mAbs, as large immunoglobulin G antibodies, require the neonatal Fc receptor and cytotrophoblast permeability to cross the placenta, which only develops after the first trimester [41]. This supports the hypothesis that treatment can be suspended once pregnancy is confirmed, as these drugs are unlikely to cross the placenta in the first 12 weeks. There are still many questions regarding the use of CGRP-mAbs in pregnant women. Further clinical studies are essential to confirm the safety of CGRP-mAbs for women planning pregnancy and to determine optimal timing for treatment cessation.

Migraine and polycystic ovary syndrome

The relationship between polycystic ovary syndrome (PCOS) and migraine has been pointed out. PCOS is one of the most common endocrine disorders in women of reproductive age, known as related to infertility. It is characterized by hyperandrogenism, ovulatory dysfunction, and polycystic ovarian morphology. PCOS is associated with several adverse health conditions, including insulin resistance, obesity, dyslipidemia, and an increased risk of type 2 diabetes and cardiovascular diseases. These hormonal and metabolic disturbances can significantly affect a woman’s overall health and quality of life.

There is a potential link between PCOS and migraine. Hormonal imbalances, particularly fluctuations in estrogen and progesterone levels, play a critical role in both conditions. Women with PCOS often experience menstrual irregularities and hyperandrogenism, which may exacerbate migraine. Additionally, common comorbidities in PCOS, such as insulin resistance, obesity, obstructive sleep apnea, and vascular dysfunction, can further contribute to the frequency and severity of migraine attacks [42].

The impact of and relationship between migraine and PCOS on reproductive health and fertility intention emphasizes the importance of comprehensive care, with neurologists and gynecologists working together. Supporting women with PCOS and migraine in making informed decisions about family planning is also essential for improving their quality of life. In addition, when researching fertility intention among such patients in the future, it will be necessary to investigate gynecological diseases such as PCOS.

Limitations

First, the focused cohort was parents, and we were unable to conduct a survey of people who did not have any children. Parents who have given up on the idea of pregnancy in the first place, and parents whose children are no longer of school age, were not surveyed. In addition, the survey did not ask both the father and mother to respond, so we could not sufficiently research into the differences between fathers and mothers. Methods other than school-based surveys will be considered, such as surveys of the entire population or surveys of patients attending headache clinics.

Second, we just asked the respondents about the presence of “headache” through the online survey. We did not diagnose migraine or confirmed migraine diagnosis by other physicians. We should interpret the result cautiously because “headache” was taken broadly rather than migraine. The majority of headaches that cause problems might be migraine, but tension-type headaches and other headaches could have a mild to severe effect on pregnancy. In order to determine whether or not it is a migraine headache, it is necessary to ask about the characteristics of the headache and the history of the physician’s diagnosis.

Third, the proportion of valid responses was as low as 20.1% (1142/5558) because the participation depended on free will. Previous similar school-based surveys were conducted as a part of the school curriculum [43, 44], so the retrieval proportion was high. We need to revise ways to increase participation and improve the survey quality. As the reason for the low participating proportion, the majority of people without headaches might ignore this survey. It is also possible that people with headaches did not participate in this survey. Headaches in some participants were so mild that they felt there was no point in participating in the survey, or that those in the other participants were so severe that they fell into a catastrophic mindset and did not feel like participating in the survey. Family, social, and economic circumstances after pregnancy also might have an effect on participation. These biases had some effect on the generalization of the results of this survey, and caution is needed in interpreting the results. Finally, the result of this study is based on self-reported data, so there might be biases.

Conclusions

We conducted a prospective school-based online survey targeting parents who experience headaches. Among the 717 participants, 678 (94.6%) reported no impact on their pregnancy plans, while 39 (5.4%) indicated they were avoiding or avoided pregnancy. Those in the avoid pregnancy group were younger, experienced more frequent and severe headaches, and had a higher incidence of headaches worsening during menstruation. They tended to felt the negative effects of headaches on pregnancy and child’s development and to form stigmas compared to the no impact group. It is crucial to educate individuals with headaches about how their condition may influence pregnancy, empowering them to make well-informed decisions regarding family planning. Especially, patients should receive better education about headaches and their treatment options to reduce their burden, the associated stigma and the negative impact on fertility intentions. Furthermore, in the long term, it is necessary to consider what kind of changes will occur in fertility intention and Japan’s declining birthrate as a result of awareness-raising activities based on our research.

Abbreviations

AMD

Monthly acute medication intake days

CGRP-mAbs

Monoclonal antibodies targeting calcitonin gene-related peptide

CM

Chronic migraine

EM

Episodic migraine

HIT-6

Headache Impact Test-6

ICHD-3

The International Classification of Headache Disorders, 3rd edition

MHD

Monthly headache days

MOH

Medication-overuse headache

NSAIDs

Non-steroidal anti-inflammatory drugs

PCOS

Polycystic ovary syndrome

Authors’ contributions

MK and NW designed and wrote this article. KI, NY, YT, YH, and KK aquired data. SK supervised this research.

Funding

None.

Data availability

We will provide the dataset based on the appropriate application.

Declarations

Competing interests

The authors declare no competing interests