Migraine and menopause

Many women with migraine have been told that migraine will improve after menopause. Should we be hanging out until our periods stop?

Menopause is the time in a woman’s life when periods have totally ceased and the ovaries no longer produce eggs. Officially, it’s when you’ve gone for 12 months without a period. Perimenopause is the time of transition before menopause when hormone levels (estrogen and progesterone) fluctuate and periods become irregular. On average, this transition takes four years, but it can be much shorter or longer.

During perimenopause and menopause, symptoms such as hot flushes, night sweats, sleep disturbances, mood swings, anxiety, brain fog, urgent need to pee (especially at night) and vaginal dryness can occur. Perimenopause often starts around age 45 but can begin earlier, or later.

Migraine can improve after menopause but unfortunately not for all women, particularly those who predominantly experience migraine with aura. And migraine may worsen during perimenopause. Both of these outcomes are more likely in people with menstrual migraine (migraine attacks around the time of the menstrual cycle), for whom hormonal changes are an obvious trigger. It may take a couple of years after periods stop for migraine attacks to reduce, as it takes time for estrogen levels to settle.

For some people, migraine attacks change during perimenopause. Some may notice a decrease in aura symptoms and others may experience aura without headache. It’s also possible for migraine attacks to occur for the first time during perimenopause, but it’s important to get these checked out by a doctor to rule out other causes of headache. Migraine doesn’t improve and may worsen when menopause is surgically induced, i.e. the womb is removed surgically (by a hysterectomy, with or without removal of the ovaries). For this reason, a hysterectomy is not recommended to treat hormonally-triggered migraine. When a woman with migraine has to have a hysterectomy for another reason, hormone replacement therapy (HRT) with estrogen is advised.

Hormone replacement therapy (HRT) can be used to even out the estrogen fluctuations and treat the symptoms associated with perimenopause, and may help with migraine. For people with migraine, HRT should be with low dose (the lowest dose possible) transdermal estrogen patches, which deliver a steady level of estrogen. This needs to be combined with progesterone if the womb is intact. The estrogen dose may need to be reduced or HRT stopped if migraine is aggravated with treatment. This is usually migraine with aura, which appears to be sensitive to high levels of estrogen; whereas migraine without aura is triggered by fluctuations in estrogen.

There is a small increased risk of stroke in younger women with migraine with aura who take estrogen in the combined oral contraceptive pill. However, patches can be used in women with migraine with aura during the perimenopause, as the estrogen doses are lower. People with risk factors for stroke or breast cancer need to discuss the risks and benefits of HRT with their doctor.

Migraine attacks can persist in the menopause since not all attacks are due to hormonal fluctuations. The usual approaches to management apply but more care may be needed when using a preventive migraine medication. As we age, our kidneys and liver can become less efficient at processing medications, leading to a higher risk of side effects or interactions with other medications. Older people taking tricyclic antidepressants such as nortriptyline (Norpress) and amitriptyline (Amirol) may be at an increased risk of developing dementia.

Menopause may not be the migraine nirvana that is sometimes promised. As at any other stage of life, the migraine brain is still present and active.

Other resources

Migraine, menopause and HRT, National Migraine Centre

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