Headache prevalence in transgender and gender diverse youth: A single-center case-control study

Assess the prevalence of headache in transgender and gender-diverse adolescents, comparing prevalence with and without exposure to gender-affirming hormone therapy.

Transgender and gender-diverse youth are an understudied group in whom we can study the effects of sex steroids on adolescents' development of headache. We hypothesized that transfeminine adolescents treated with estrogen would have higher odds of headache than those not treated, and that transmasculine adolescents treated with testosterone would have lower odds of headache than those not treated.

This retrospective case-control study analyzed all patients seen at the Boston Children's Hospital Gender Multispecialty Service clinic from 2007 to 2017. Cases were defined as patients with headache, controls as those without headache, and exposure as treatment with gender-affirming hormone therapy (i.e., estrogen or testosterone). A computerized search identified cases that were then validated by chart review.

Fifty-two of the 763 transgender and gender-diverse patients seen were confirmed to have headache. Of 273 transfeminine patients 45% (123/273) received estrogen treatment. Transfeminine patients receiving estrogen were more likely to have headache than those not receiving estrogen (7% [9/123] vs. 1% [2/150]; odd ratio [OR] 5.84 (95% confidence interval [CI] 1.24-27.6), p = 0.026). Of 490 transmasculine patients, 46% (227/490) received testosterone. Transmasculine patients receiving testosterone were more likely to have headache than those not receiving testosterone (12% [28/227] vs. 5% (13/263); OR 2.71 (95% CI 1.37-5.4), p = 0.005).

Among transfeminine and transmasculine youth, those who received gender-affirming hormone therapy had higher odds of headache compared to those not taking gender-affirming hormone therapy. Further prospective studies to guide headache care of transgender and gender-diverse youth and adults are needed. Our results could be generalizable to other pediatric gender management clinics and may be worth discussing with patients considering treatment.