Changes in hormone levels can intensify migraine attacks. Learn about how menstruation, menopause and hormone replacement therapy can affect migraine symptoms.
1 in 5 women experience migraine, and for nearly 2 out of 3 women with migraine, attacks occur at the same time as their period. For women, fluctuations in hormone levels, specifically estrogen, during their lifetime can bring on new migraine symptoms and changes in symptom severity.
Changes in estrogen levels at the beginning of a woman’s menstrual cycle can cause more severe attacks. They also last longer and involve greater light sensitivity than attacks at other times of the month. Attacks can also worsen when hormone levels rise of fall either after giving birth or in the transition to menopause. Many women actually find their migraine symptoms are less frequent and intense during the last six months of pregnancy.
Menstrual Migraine—Migraine Before a Period
Menstrual migraine attacks occur in the two days before a woman’s period and the first three days of flow. These are times when estrogen levels drop. These attacks are generally more intense and longer than attacks at other times of the month. Attacks can also happen during and after a period.
Keep a headache and cycle diary if you think your migraine attacks are related to your menstrual cycle. Note the timing and specific symptoms, as this may help your doctor determine whether you have menstrual migraine and which treatment is best for you.
Menopause and Migraine
Menopause brings more stable hormone levels. So many women find their migraine attacks decrease or go away once their periods stop. However, the transition to menopause, called perimenopause, can make migraine symptoms worse before they get better. During perimenopause, periods become more irregular, causing unpredictable hormone changes. Overall, estrogen levels start to decline. That sudden drop in estrogen levels, which eventually causes a woman’s periods to stop permanently, can trigger migraine attacks.
Besides irregular periods, perimenopause can bring other symptoms such as hot flashes, night sweats, vaginal discomfort and dryness. Hormone replacement therapy is an option to treat these symptoms. Some women find hormone therapy also relieves migraine pain, while others feel it makes their migraine attacks worse.
Hormone Replacement Therapy
Hormone replacement therapy (HRT) are medications that contain female hormones. Typically used to treat common menopausal symptoms, HRT replaces some estrogen that decreases during the transition to menopause. Estrogen can be taken as a pill or patch or delivered vaginally through a cream, vaginal ring or spray.
HRT can be helpful for some women, but it’s not for everyone. There is an increased risk of heart disease, stroke, blood clots and breast cancer associated with HRT. This is dependent on age, type of therapy and health history. And for some, HRT does not reduce symptoms. It’s important to discuss your individual health risks and symptoms with your doctor to determine if HRT is suitable for you.
HRT for Gender Transitioning
Many transgender men and women use hormone therapy during the transitioning process. For transgender people with migraine, changes in hormone levels can contribute to migraine attacks, though it’s likely not the only factor.
While each person can react differently to HRT, it’s possible that the use of HRT while transitioning can affect the frequency and intensity of migraine attacks. There isn’t much data on transgender people who go through HRT and how it affects migraine. But research shows consistent hormone therapy can reduce migraine frequency. This is especially helpful for people who typically experience menstrual migraine.
Transgender people don’t have to choose between hormone therapy and migraine management. Because of the relationship between hormones and migraine, it’s important to talk to your doctor about whether specific migraine medications may interact with HRT and how HRT may affect the frequency of migraine attacks.
Treatment for Hormonal and Menstrual Migraine
If you experience migraine attacks associated with your menstrual cycle or hormone changes in perimenopause (the months leading up to menopause), talk to your doctor about treatment options. You don’t have to accept migraine attacks as a part of your hormonal shifts each month or your transition to menopause. There are many options for acute and preventive treatments.
Oral tablets, injectables and nasal sprays can provide acute relief when an attack occurs. But preventive treatments can also be helpful for hormonal and menstrual migraine. In a mini-prevention approach, a woman will take medication, either NSAIDs, estrogen supplementation, triptans or do short-term prevention with rimegepant (Nurtec) in the days leading up to her period. Taking magnesium from day 15 of the menstrual cycle through the next period is another mini-prevention strategy. This relies on the timing of the previous period, so it can be a good option for those with irregular periods. Note that none of these approaches are FDA-approved at this time, and they are not recommended in women who have migraine with aura or other risk factors for stroke.
Maintaining a continuous dose of birth control—by taking pills or using a vaginal ring with no placebo week—can be an effective preventive treatment for migraine in women with hormonal headache triggers. This is because a continuous dose of birth control prevents shifts in estrogen that can cause menstrual migraine attacks. A steady preventive approach is helpful for women with irregular periods or those who don’t respond to a mini-preventive treatment strategy.
Taking estrogen to stabilize hormone levels doesn’t always work to treat migraine. Whether it’s from birth control or HRT, estrogen can have an unpredictable effect. It may decrease migraine frequency, trigger attacks or do nothing at all. Your doctor can help you find the proper treatment based on your migraine symptoms, menstrual or perimenopausal symptoms, cycle timing and personal risk factors.
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Reviewed for accuracy by the American Migraine Foundation’s subject matter experts, headache specialists and medical advisers with deep knowledge and training in headache medicine. Click here to read about our editorial board members.