Migraine During Perimenopause and Menopause

Migraine During Perimenopause and Menopause

Medically reviewed by: Caroline Stowe, DNP, FNP-BC, AAHIVS, AQH, MSCP

Growing older changes many things in your body, including migraine disease. Your symptoms, reactions to medications, and risk factors for certain treatments may all change as you age. The hormonal fluctuations leading up to menopause can trigger dramatic changes in the way you experience migraine.

If you’ve ever heard the saying, “menopause stops migraine,” the truth is more complex. What experts know now about migraine and aging can help you manage those complications more comfortably and effectively.

Menopause vs. Perimenopause

Perimenopause is the transitional time leading up to menopause, typically lasting about 4 to 8 years (although it may be much shorter or longer for some people). It can begin as early as the mid-thirties in some women, with the majority of women entering perimenopause in their 40s.

The fluctuating hormones of perimenopause are the culprits behind the notorious symptoms like hot flashes, weight gain, mood changes, insomnia and forgetfulness. They can also have a dramatic impact on migraine.

Menopause is the end of menstruation, most often defined as the period following 12 months without a menstrual period. It typically happens around a person’s early 50s. 

Migraine and Perimenopause

Hormonal fluctuations, especially the rise and fall of estrogen, often make menstrual periods irregular in schedule, cause heavier bleeding, and trigger symptoms like hot flashes and insomnia. Migraine attack frequency and severity may increase, even if they were well-controlled and stable before perimenopause. Fluctuating estrogen levels are believed to affect several factors in the pathology of migraine (like neurotransmitters and other hormones), making the brain more sensitive to migraine attacks. 

Perimenopause symptoms can also affect your migraine threshold. Hot flashes and insomnia can interrupt your sleep, making you more vulnerable to attacks. Heavy menstrual bleeding isn’t just physically draining but can also trigger an increase in prostaglandins and iron deficiency, both of which may worsen migraine attacks.¹

The perimenopausal transition is different for everyone. Some people who have migraine attacks before perimenopause may advance through the transition years with minimal changes in migraine symptoms. Others who’ve never had migraine attacks before, or whose symptoms were mild enough to ignore, may experience their first identifiable migraine attacks during perimenopause.

What should you do if your migraine symptoms worsen during perimenopause?

  1. Talk to your healthcare provider. Do you have perimenopause symptoms like hot flashes, anxiety/depression and sleep disturbances along with changes in your migraine pattern? This information will help your healthcare provider recommend effective options.
  2. You may need to start a preventive regimen for migraine if you haven’t already or change an existing regimen if it isn’t working as well as it used to. The good news is that there are several new treatments available, including some that were originally created to be acute treatments but have received expanded indications for migraine prevention (like gepants and neuromodulation devices).
  3. There are non-hormonal options for relieving symptoms like hot flashes, such as the off-label use of medications like venlafaxine and gabapentin. These options may help some people but be unsafe or inappropriate for others, so talk to your healthcare provider about your specific situation, risks, and potential benefits.

Migraine and Menopause

It was once widely believed that when menstruation stopped, so did migraine attacks. While there is limited research on migraine after menopause, existing studies and common clinical observations among headache experts suggest that menopause is a mixed bag for people with migraine. 

After menopause, the majority of people with migraine will experience a significant reduction or even disappearance of migraine attacks, but it may take a few years as the hormonal fluctuations settle—think of menopause as a dimmer switch, not an on-off switch. Symptoms may become milder or change after menopause, often requiring adjustments in treatment.

On the other hand, certain groups of patients may get less relief from menopause. People whose first attacks occurred in childhood or adolescence tend to have persistent migraine symptoms after menopause, as do people with chronic migraine (15 headache days or more per month for at least 3 months). Some of these patients may eventually have reductions in migraine burden following menopause, but the improvements may be slower and less dramatic.

What About Hormone Therapy?

Low-dose hormone therapy may be a suitable treatment for certain perimenopausal and menopausal patients, especially those with low baseline cardiovascular risks who start treatment in their 40s and 50s. For people with migraine, the risk-benefit analysis is always complicated, given that certain migraine types are associated with higher cardiovascular risks.

The type of hormonal therapy prescribed also varies depending on the stage of menopause. If other treatment regimens haven’t provided sufficient relief from menopausal and migraine symptoms, and your age and other risk factors are relatively low, talk to your healthcare provider about whether hormone therapy is safe for you to try.

Risks of Surgical Menopause With Migraine

Surgical menopause occurs when the ovaries are removed prior to menopause triggering the onset of menopause. The ovaries may be removed due to chronic pelvic pain, ovarian cysts, endometriosis, or a hysterectomy that also removes the fallopian tubes and ovaries.² Removal of the ovaries can cause a rapid decline in hormones like estrogen and progesterone. Surgical menopause worsens migraine in 2 of 3 women whereas natural menopause improves migraine in 2 of 3 women.³

Surgical menopause should never be performed to reduce the frequency, severity or disability of migraine.³

If your surgery or procedure will result in menopause and you have migraine disease, it’s important to discuss all treatment options with the entire healthcare team ahead of time, if possible. Hormonal therapy may be a safe option, at least short-term, for some patients with migraine —but it is not safe for everyone. In addition, surgical menopause may increase the risk of developing a number of conditions, including heart disease and osteoporosis. — so there are many factors that need to be considered.

Navigating perimenopause and menopause can be challenging for people living with migraine. While some may experience an improvement in their migraine attacks, about a third of people do not get better. Hormonal fluctuations and surgical procedures can exacerbate symptoms for many people. To try to improve quality of life during this transition period, it is generally recommended to consult with a healthcare provider to explore different migraine treatment options, hormonal therapies and “off-label” migraine treatments that may also help menopausal symptoms.

References

  1. ​​https://www.verywellhealth.com/perimenopause-and-migraines-4009311
  2. https://my.clevelandclinic.org/health/treatments/17800-oophorectomy 
  3. https://americanmigrainefoundation.org/resource-library/understanding-migrainehysterectomy-and-migraine-what-can-you-expect/
  4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5972479/#:~:text=Surgical%20menopause%20is%20associated%20with,plaque%2C%20and%20increased%20CVD%20events.

Authors

Lisa Smith

Lisa had migraine attacks for most of her adult life before being diagnosed with migraine disease. A communications strategist, writer, and former radio announcer, she lives in the Boston area, where she advocates for her fellow migraine patients every chance she gets.

Kylie Petrarca is a Registered Nurse and has experience in both medical-surgical nursing and critical care. Her passion for patient care led her to a new role in 2021 as the Education Program Director for the Association of Migraine Disorders. Kylie also lives with chronic migraine and is a student in the Master of Headache Disorders program at the University of Copenhagen.

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