Dyspareunia and pelvic pain in women with chronic migraine: A retrospective, observational analysis

Liza Smirnoff: Conceptualization; methodology; writing – original draft; writing – review and editing. Leon S. Moskatel: Conceptualization; formal analysis; methodology; validation; writing – review and editing.

LS and LSM report no funding for this project.

We conducted a retrospective cohort analysis using a logistic regression analysis to determine the impact of chronic migraine on rates of dyspareunia and pelvic pain in women. All data were obtained through the Stanford Research Repository (STARR), and this project received approval from the Stanford Institutional Review Board (IRB‐74800). The requirement for informed consent was waived by the IRB as the chart review represented minimal risk to patients. STARR is an aggregated database of Epic Systems electronic health records derived from Stanford‐affiliated providers and maintained by the Stanford School of Medicine. Data are available both for aggregate analysis and individual chart review through the STARR online self‐provisioned chart review. Groups for assessment were built on different diagnostic criteria but were drawn from female patients who were seen in the Stanford Headache Clinic, a tertiary headache center, or the Comprehensive Neurology Clinic in the Department of Neurology between January 1, 2022, and March 24, 2024. Patient groups were then created for two scenarios based on combinations of International Classification of Diseases, Tenth Edition (ICD‐10) codes that were assigned during the specified time frame. Sample size was determined by the number of patients who met the criteria. We did not conduct an a priori power analysis to determine if this was a sufficient sample size to detect differences. Demographics for each group were determined including race–ethnicity, marital status, and average age. The first scenario examined dyspareunia and multiple causes of pelvic pain in women with chronic migraine relative to women without migraine. Dyspareunia was defined as ever having an ICD‐10 code of N94.1; N94.1 for vaginismus, N94.81 for vulvodynia, R10.2 for pelvic pain, N30.1 for interstitial cystitis. Chronic migraine was defined as the group who had ever received a G43.7 ICD‐10 code. The group with “no migraine” was defined as never receiving a G43 diagnosis. In the second scenario, dyspareunia in patients with chronic migraine and comorbidities was assessed. Groups were built based on the presence of chronic migraine and the presence or absence of ICD‐10 codes: F32 and F33 for depression, F41 for anxiety, F43.1 for post‐traumatic stress disorder (PTSD), K58 for IBS, M79.7 for fibromyalgia, Z37 to indicate a history of giving birth, younger (18–50 old) and older (greater than 50 years old) age, N80 for endometriosis, R10.2 for pelvic pain, N94.2 for vaginismus, N94.81 for vulvodynia, and N30.1 for interstitial cystitis. The primary outcomes were the prevalences of dyspareunia, vaginismus, vulvodynia, pelvic pain, and interstitial cystitis in women with chronic migraine relative to women without migraine. Secondary outcomes included the prevalences of dyspareunia in women with chronic migraine who also had depression, anxiety, endometriosis, PTSD, IBS, fibromyalgia, history of childbirth, and older age relative to those without these conditions. This is the primary analysis of these data. Missing data included 753 patients without a reported race and 784 patients without a reported ethnicity; 620 patients had no reported race or ethnicity. Marital status was not reported in 524 patients. Demographics for the groups were first considered. Age was reported as a continuous variable, with average and standard deviations reported for both the patients without migraine and those with chronic migraine. Race–ethnicity and marital status were reported as categorical variables according to categories pre‐determined by the electronic health record for both patients without migraine and those with chronic migraine. Race (recorded as Asian, Black, Native American, other, Pacific Islander, unknown, and White) and ethnicity (recorded as Hispanic/Latino, non‐Hispanic/non‐Latino, and unknown) are recorded separately in our electronic health record but we have elected to use the composite “race–ethnicity” to better reflect our patients’ identities; additional ethnicity information beyond Hispanic/Latino and non‐Hispanic/non‐Latino was not available. The category of “unknown” reflects unavailable data. Data were aggregated in Microsoft Excel and then imported into Stata release 14 (StataCorp LLC, College Station, TX, USA) for analysis. Multivariable logistic regressions with odds ratios (ORs) with 95% confidence intervals (CIs) were used as the primary statistical test for the primary and secondary outcomes. Age, race–ethnicity, and marital status were controlled for as part of the multivariable regression to give adjusted ORs. These variables were chosen for the multivariable regression as these demographic factors were statistically significantly different between the “no migraine” and “chronic migraine” groups; the pelvic pain conditions and comorbid conditions were not included in the regression as they were outcome variables or included in subsequent regressions. Age, race–ethnicity, and marital status were confirmed to be independent and not colinear, with a correlation matrix with race–ethnicity and marital status first encoded as dummy variables (Table  S1 in supporting information ). A two‐sided independent sample t ‐test was used to assess differences in ages between groups and their controls. Chi‐squared testing was used to determine differences in other categorical variables. Statistical significance was set at a two‐sided p  < 0.05.

A total of 3856 patients with chronic migraine and 5614 patients without migraine met inclusion criteria. Demographics and prevalence of the queried conditions for the “no migraine” and “chronic migraine” groups are in Table  1 . The patients without migraine were an average of 12.4 years older than those with chronic migraine (no migraine: 58.3 ± 19.3 years old; chronic migraine: 45.9 ± 15.5; p  < 0.001). The race–ethnicity composition also showed a statistically significant difference as did marital status (for both: p  < 0.001). Summary of patients without migraine and those with chronic migraine. ORs, adjusted for age, race–ethnicity, and marital status, were increased for all pelvic pain conditions assessed in women with chronic migraine, including for having dyspareunia or any type of pelvic pain (OR 2.46; 95% CI: 2.17–2.79, p  < 0.001; Table  2 ). Interstitial cystitis was noted to have the highest OR in women with chronic migraine (OR 3.04; 95% CI: 1.98–4.66, p  < 0.001), followed by vaginismus (OR 2.51; 95% CI: 1.29–4.88, p  = 0.007), pelvic pain (OR 2.48; 95% CI: 2.17–2.84, p  < 0.001), dyspareunia (OR 1.97; 95% CI: 1.57–2.49, p  < 0.001), and vulvodynia (OR 1.88; 95% CI: 1.04–3.40, p  = 0.036). Outcomes of univariable and multivariable logistic regressions for the presence of pelvic pain conditions in patients with chronic migraine relative to those without migraine. Abbreviation: CI, confidence interval. We then assessed the impact of specific factors and comorbid conditions on the risk of dyspareunia in patients with chronic migraine (Table  3 ). In women with chronic migraine, vulvodynia (OR 13.55; 95% CI: 6.39–28.74, p  < 0.001) and vaginismus (OR 11.93; 95% CI: 5.90–24.10, p  < 0.001) were noted to have the highest magnitude adjusted OR for dyspareunia. The other conditions assessed in the primary outcomes were noted to have elevated OR for dyspareunia in patients with chronic migraine including interstitial cystitis (OR 8.11; 95% CI: 4.72–13.89, p  < 0.001), pelvic pain (OR 7.11; 95% CI: 5.60–9.04, p  < 0.001), and endometriosis (OR 5.24; 95% CI: 3.73–7.35, p  < 0.001). Comorbidities that can also be seen in patients with chronic migraine also independently increased the OR for dyspareunia in patients with chronic migraine including fibromyalgia (OR 3.93; 95% CI: 2.81–5.49, p  < 0.001), IBS (OR 3.92; 95% CI: 2.94–5.22, p  < 0.001), anxiety (OR 3.19; 95% CI: 2.55–3.99, p  < 0.001), PTSD (OR 3.14; 95% CI: 2.18–4.52, p  < 0.001), depression (OR 2.80; 95% CI: 2.22–3.53, p  < 0.001), and older age (OR 1.53; 95% CI: 1.18–1.98, p  = 0.001). A history of giving birth was associated with an increased unadjusted OR for dyspareunia in chronic migraine, but this was not statistically significant after adjusting for confounding factors. Outcomes of univariable and multivariable logistic regressions for dyspareunia in patients with chronic migraine and an additional condition. Abbreviation: CI, confidence interval.

Migraine commonly co‐occurs with other chronic pain conditions and has been shown to have a prevalence as high as 67% in persons with pelvic pain, which can result in not only migraine‐related disability but increased disability related to the comorbid pain condition. 1 Common causes of pelvic pain, such as endometriosis, have also separately been shown to occur at higher rates in women with migraine. 2 , 3 Sexual dysfunction is commonly comorbid in persons with migraine, occurring in 41% of patients in one study, with those with higher headache frequency disproportionally more affected. 4 Sexual dysfunction was also more common in patients who experienced comorbid depression. 5 Furthermore, chronic pain and medical conditions in general can have significant negative effects on sexual satisfaction, with patients with migraine reporting greater degrees of pain during intercourse and higher levels of fear of sexual intercourse. 6 This suggests not only comorbidity but perhaps a direct effect of migraine on sexual function. Dyspareunia is a common condition of pelvic pain and sexual dysfunction and is defined by painful sexual intercourse. It occurs in approximately 10–20% of women in the United States and its prevalence varies with age. 7 It continues to be underdiagnosed due to stigma, lack of reporting, and lack of comfort for many providers with both screening and recognizing sexual dysfunction, and creating an appropriate management plan for the patient. 8 Causes of dyspareunia are numerous and can include inadequate lubrication, pelvic floor dysfunction, vaginitis, vulvodynia, or vaginismus, as well as deeper causes such as endometriosis or anatomic defects. Left untreated, dyspareunia has been shown to significantly affect sexual and psychological well‐being. 9 Notably, both persons with migraine and those with dyspareunia have increased comorbid rates of depression, anxiety, irritable bowel syndrome (IBS), as well as a prior history of sexual abuse and pelvic pain. 10 , 11 , 12 Additionally, women experiencing dyspareunia have been shown to experience higher levels of stress, lower self‐efficacy, and lower pain thresholds in comorbid fibromyalgia, all factors known to have a worsening effect on chronic migraine. 13 , 14 Pelvic pain conditions such as dyspareunia are not commonly screened for in patients with migraine despite having multiple overlapping comorbid conditions as well as a potential impact of headache on sexual function. Likewise, the possibility of a bidirectional relationship between chronic migraine and dyspareunia is unknown. We hypothesized that patients with chronic migraine had higher rates of dyspareunia and pelvic pain conditions than patients without migraine.

Our study revealed that patients with chronic migraine seen by the Stanford Headache Clinic between 2022 and 2024 had a significantly increased likelihood of pelvic pain conditions. Women with chronic migraine had a 22.5% prevalence of dyspareunia or pelvic pain, compared to 9.5% in the population of patients without a known history of migraine. Likewise, specific types of pelvic pain, such as dyspareunia, endometriosis, vaginismus, and interstitial cystitis, were all elevated. These conditions are known to have a component of central sensitization, similar to chronic migraine. 15 , 16 An animal model of endometriosis demonstrated increased pain sensitivity to pain in other areas of the body. 17 In humans, dyspareunia was also a risk factor for the development of central sensitization. 18 While no studies currently exist to examine the association between central sensitization in migraine and pelvic pain, the shared pathophysiology suggests a relationship between the two pain conditions or the influence of one condition on the other, as demonstrated in our study. Furthermore, dyspareunia attributed to central sensitization has been shown to respond to therapies such as tricyclic antidepressants (TCAs), acupuncture, and psychological treatments, such as cognitive behavioral therapy and mindfulness‐based therapy, which are also all known to be useful in the management of chronic migraine. 19 Identifying patients who may experience both conditions can lead to decreased symptoms of both conditions. In patients with ongoing pelvic pain, sexual dysfunction must also be considered when selecting migraine therapy. Chronic conditions can already negatively impact sexual function, so care must be taken to limit medications that further negatively affect sexual function. 20 Antidepressants have been shown to adversely impact both arousal and sexual satisfaction, in particular selective serotonin reuptake inhibitor (SSRI) and serotonin–norepinephrine reuptake inhibitor (SNRI) medications, with less impact attributed to TCAs. 21 , 22 As previously shown, comorbidities commonly seen in chronic migraine, such as IBS, fibromyalgia, anxiety, depression, and PTSD, were all elevated in the dyspareunia cohort. Shared comorbidities may confound the clinical picture and make both conditions more difficult to treat. Effective screening for pelvic pain and dyspareunia in patients with chronic migraine can improve their overall quality of life and potentially impact shared comorbid conditions. Historical questions should include history of pelvic pain, sexual dysfunction, trauma, known history of prior sexually transmitted infections, and bladder symptoms. 23 Care must be taken to establish trust and consent obtained from the patient to ask questions regarding pelvic pain. Limitations to our study included significant likely underreporting of pelvic pain conditions, unknown pelvic pain conditions when women were treated for them outside of the Stanford Health system, and lack of assessment for these conditions when completing the headache intake by most providers. Furthermore, the retrospective design limits control over sampling of the population, and the nature and quality of diagnostic information. Additional limitations to this study included the need to rely on ICD‐10 codes in aggregate data, which can lead to potential misclassification of conditions, as well as under‐ or overdiagnosis of conditions. Additionally, as this was a group of patients seen at a tertiary headache center, the likelihood and prevalence of pelvic pain conditions present in this group may not be representative of other settings, although the authors suspect significant underreporting. Further study is additionally needed into the presence of pelvic pain and dysfunction in men with chronic migraine. The race and ethnicity data are also suboptimal for best understanding our patients’ ethnic backgrounds and identities. While our electronic health record has a dichotomy of race and ethnicity, it currently does not allow for a more expansive and inclusive categorization method that enables patients to best express their identity.

Pelvic pain conditions are common in women with chronic migraine and share many known comorbidities, such as mental health conditions and IBS. Our study demonstrated an increased prevalence of dyspareunia, vaginismus, vulvodynia, and interstitial cystitis in women with chronic migraine. Additionally, the rates of IBS, fibromyalgia, anxiety, depression, and PTSD were all increased in women with a history of dyspareunia and are known to be comorbid with chronic migraine. Given the significant overlap in pathophysiology and the comorbid nature of these conditions, headache providers should screen women with chronic migraine for comorbid pelvic pain to connect them with appropriate treating physicians. This, and initiating therapies that benefit both patients’ chronic migraine and pelvic pain, can positively impact their overall health and pain‐related disability.

Liza Smirnoff and Leon S. Moskatel declare conflicts of interest.

Table S1.