Why do women with epilepsy experience seizure spikes around periods?

Experts explain how hormonal shifts across the menstrual cycle can trigger seizure clusters in some women with epilepsy and what can help manage the risk

For many women living with epilepsy, seizures do not always occur at random. Instead they tend to cluster around certain days of the month, which can feel both distressing and puzzling.

 

Studies suggest that up to 40 per cent of women with epilepsy may experience seizure worsening linked to their menstrual cycle. Doctors refer to this pattern as catamenial epilepsy, and it underscores the powerful connection between hormonal shifts and brain activity. Experts say the pattern often goes unnoticed because seizures and periods are not routinely tracked together.

 

What is catamenial epilepsy?

 

Dr Praveen Gupta, chairman - Marengo Asia International Institute of Neuro & Spine (MAIINS), Marengo Asia Hospitals, Gurugram, explains that catamenial epilepsy refers to a predictable worsening of seizures during certain phases of the menstrual cycle.

 

 

He says the pattern is driven by the natural fluctuations of oestrogen and progesterone. Oestrogen generally increases brain cell excitability, whereas progesterone has a calming and protective influence. Dr Gupta notes, “Estrogen tends to be pro-convulsant whereas progesterone and its metabolite allopregnanolone are anti-convulsant.”

 

Building on this, Dr Vivek Barun, senior consultant-neurology and epilepsy, Artemis Hospitals, says, “When progesterone levels drop suddenly before periods the protective effect goes down. This makes some women more likely to have seizure spikes at certain times of their cycle.”

 

When progesterone falls and oestrogen remains relatively higher, the balance shifts towards greater brain excitability. For women who already have epilepsy, this shift can temporarily lower the seizure threshold and increase the likelihood of clustering.

 

Which phases of the menstrual cycle are most risky?

 

Experts describe three main patterns in which seizure spikes are more common. These phases are associated with a higher likelihood of seizures because they are marked by hormonal imbalance, particularly lower progesterone levels, which normally help stabilise brain activity, explains Dr Sadique Pathan, consultant neurologist, Sahyadri Hospitals, Hadapsar.

 

• The perimenstrual phase (just before and during periods), when progesterone levels drop sharply
• The periovulatory phase (around ovulation), when estrogen peaks
• The luteal phase in women with irregular cycles or inadequate progesterone levels

 

Who is more vulnerable?

 

Not every woman with epilepsy experiences catamenial patterns. However certain groups appear more at risk.

 

Women with focal epilepsy, especially temporal lobe epilepsy, report cycle-linked worsening more commonly. Those with drug-resistant or poorly controlled seizures may also be more sensitive because even small hormonal shifts can tip the balance.

 

Experts also highlight additional risk factors:

 

• Irregular or anovulatory cycles
• Polycystic ovarian syndrome (PCOS)
• Hormonal imbalances or thyroid disorders
• Adolescence
• Women not responding fully to anti-seizure medication

 

Dr Pathan notes that women with intractable seizures and hormonally sensitive migraines may also be prone to catamenial seizure activity.

 

"External factors like stress, sleep deprivation, and missed medications during menstruation can further increase seizure risk," adds Dr Rathijit Mitra, neuro-surgeon at CK Birla Hospitals, CMRI.

 

How is catamenial epilepsy diagnosed?

 

There is no single blood test or scan that confirms catamenial epilepsy. Instead diagnosis relies on pattern recognition. Doctors usually recommend:

• Keeping a seizure diary alongside a menstrual calendar for at least three months
• Looking for a consistent doubling or clear rise in seizures during specific cycle phases
• Checking medication adherence and possible triggers

 

If cycles are irregular, doctors may check hormone levels or confirm ovulation. Electroencephalogram (EEG) or imaging may be used to rule out other causes, but the diagnosis remains largely clinical.

 

Dr Barun explains that it differs from random seizure worsening because it shows “a clear cyclical pattern that is linked to menstruation, not stress, lack of sleep and missed medication". 

 

How can women manage cycle-linked seizures?

 

Management is individualised and usually added to baseline anti-seizure therapy. The goal is to target high-risk days while maintaining overall safety.

 

Medication strategies

 

• Optimising regular anti-seizure medicines
• Short-course treatments such as clobazam or acetazolamide during vulnerable days
• Adjusting doses around high-risk windows under medical supervision

 

Hormonal approaches

 

• Supplementary natural progesterone in selected cases
• Continuous hormonal contraception for menstrual suppression in some women
• Specialist therapies in resistant cases

Experts stress that decisions must be carefully coordinated between neurologists and gynaecologists because drug interactions and pregnancy planning are important considerations.

 

Lifestyle strategies

 

• Track seizures and periods consistently
• Maintain regular sleep patterns
• Reduce stress and stay hydrated
• Avoid alcohol and missed medication
• Plan safety measures during high-risk days

 

For women whose seizures remain poorly controlled, neuromodulation therapies offer new hope, shares Dr Mitra.

 

"The Vagal Nerve Stimulator (VNS) is an implantable device that delivers controlled electrical signals to the vagus nerve, helping stabilise abnormal brain activity. Newer-generation VNS devices are more precise and responsive, offering sustained seizure control without being affected by hormonal fluctuations, making them particularly useful for women with catamenial epilepsy," he says.

 

Catamenial epilepsy highlights how closely the brain and hormones are connected. With awareness, careful tracking and coordinated care, many women can reduce seizure spikes and regain a greater sense of predictability in their lives.

   

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This report is for informational purposes only and is not a substitute for professional medical advice.