During menopause, hormone changes can affect migraine symptoms. Learn about the different stages of menopause and how hormone changes may impact migraine.

Women experience hormone shifts throughout their lives, including during a menstrual cycle, pregnancy, breastfeeding and menopause. Because changes in hormone levels can affect migraine symptoms, menopause is a particularly challenging time for women who live with migraine. Being prepared for how these hormone changes may affect your migraine symptoms can help you more effectively manage your migraine through the stages of menopause.

The American Migraine Foundation recently hosted a webinar on Migraine and Menopause featuring Dr. Susan Hutchinson, a headache specialist and founder of Orange County Migraine and Headache Center. Prior to receiving her certification in headache medicine, Dr. Hutchinson spent 22 years serving as a family medicine provider and worked with many women on managing hormones. Understanding the connection between hormones and migraine is one of her passions.

The Stages of Menopause

During the webinar, Dr. Hutchinson discussed how menopause can affect one’s approach to managing migraine symptoms. Specifically, she notes that the different stages of menopause often impact one’s hormone levels, migraine symptoms and the specific treatment options that are likely to be effective.

What is perimenopause?

Perimenopause refers to the transitional period that occurs in the months or years before menopause. This period is marked by fluctuating hormone levels, including a decrease in the body’s production of estrogen. The average age for perimenopause is 47-51 years old, but it can start earlier. If it begins before age 40, it’s considered premature perimenopause.

How does perimenopause affect migraine treatment?

Prior to perimenopause, many women who experience menstrual migraine are able to manage their symptoms through preventative treatment planned to coincide with their regular menstrual cycle. This may include taking preventative medication or using other preventative strategies before and during their period to minimize the chance and/or severity of an attack.

However, as a woman enters perimenopause and experiences hormone changes, the length of her cycle may change or become irregular. This can make it significantly harder to anticipate and manage migraine attacks through preventative treatments.

Additionally, the symptoms of perimenopause can increase the risk of migraine attacks by contributing to issues like loss of restful sleep. For example, perimenopause often brings symptoms like hot flashes, night sweats and insomnia. These disruptions to one’s sleep schedule can lead to worsening migraine as well as mood changes like depression and irritability.

Dr. Hutchinson notes that in many cases, these changes may require revisiting one’s treatment plan with a doctor and taking a different approach. “For a woman who didn’t need [migraine] prevention or was just using a single preventive agent, when she hits perimenopause, she may need a more aggressive preventive approach,” says Dr. Hutchinson.

What is menopause?

Menopause refers to the end of a woman’s natural menstrual cycles. Menopause officially begins after spontaneous menses (menstral bleeding) stops for a full 12 months. Dr. Hutchinson notes that this applies to natural menstruation cycles not currently being affected by hormones or birth control.

While it’s not necessary for diagnosis, menopause can be confirmed through a blood test that measures hormone levels—specifically, estradiol (the primary form of estrogen) and follicle stimulating hormone (FSH). The average age that menopause begins is 51 years old.

At this point, migraine symptoms may actually improve because hormone levels are no longer changing as significantly and frequently as in perimenopause. However, for some women whose estrogen levels are too low, migraine symptoms may continue to change or worsen. Additionally, women who have non-hormonal triggers—like changes in barometric pressure, stress or lack of sleep—will still have migraine attacks due to those triggers.

“The majority of women over the years have had what’s called menstrual-related migraine,” says Dr. Hutchinson. “So yes, they have migraines triggered by menses, but they also have migraines from many other triggers… Often [migraine attacks] don’t completely go away or get better until you’re later in the menopausal years.”

Surgical menopause is when the ovaries are removed before a woman has gone through natural menopause. Ovaries may be removed for a variety of reasons, including cysts, ovarian torsion or breast cancer.

“If the ovaries are taken out before a woman has gone through spontaneous menopause, the implications for having migraine exacerbation [worsening] are incredible,” says Dr. Hutchinson. “If women go through spontaneous menopause, about two-thirds should expect to have their migraines improve. If women are thrown into menopause by having their ovaries removed before they have gone through menopause, only about a third may improve.”

If you are facing surgical menopause, Dr. Hutchinson suggests having your gynecologist and headache specialist work together to create a treatment plan. If a woman must have her uterus removed and does not also need to have her ovaries removed, then Dr. Hutchinson recommends leaving the ovaries to allow the woman to go through menopause naturally.

Early vs. Later Menopausal Years

The best treatment plan may depend on whether a woman is in the early or later years of menopause. The early menopausal years are typically from age 51 to 60. “For many women, whether you have migraine or not, the benefits of hormonal therapy often outweigh the risks [at this stage],” says Dr. Hutchinson.

Dr. Hutchinson defines the later menopausal years as those after age 60. At that point, starting hormone therapy may not be the best option due to the increased risk of coronary heart disease, stroke, blood clots and dementia. Certain types of treatments—like hormonal patches and gels—or lower doses of hormone therapy may help reduce these risks.

Hormone Therapy for Menopause

She explains that helping control migraine is not the main reason for using hormone therapy during menopause, but that it could be a useful side benefit for many women. The primary reasons Dr. Hutchinson gives for using hormone therapy during menopause include:

  • Very uncomfortable vasomotor symptoms (hot flashes, night sweats and insomnia)
  • Genital or urinary symptoms, such as dryness due to lack of estrogen
  • Slowing or preventing bone density loss and fractures for women with a high risk of osteoporosis

Dr. Hutchinson says it is safer to start hormone therapy earlier in menopause. She recommends using the lowest dose necessary for the shortest amount of time—perhaps the first three to five years of menopause.

Estradiol (estrogen) patches are the most common type of hormone replacement therapy Dr. Hutchinson prescribes. “The estradiol goes directly from the skin into the blood system,” she explains. “It bypasses the gastrointestinal (GI) system and you can get a very nice steady-state estrogen level—and that actually can be measured with a blood test to help guide the provider.”

In more recent years, there has been a shift away from synthetic hormone treatments toward natural hormone treatments. Synthetic hormones are artificially manufactured. For example, some synthetic estrogen treatments are produced by altering hormones from pregnant mares. Natural hormone treatments—sometimes called bioidentical hormones—have “the same chemical molecular structure as your own ovaries produced when you were younger,” says Dr. Hutchinson.

Dr. Hutchinson says she prefers natural hormone formulations in cases where someone is at risk for other health issues like stroke or heart disease. She has found that in these cases natural hormone treatments have a lower chance of triggering migraine symptoms or negatively impacting these other health risks. Natural hormones also seem to have a positive effect on mood and sleep, which can help reduce migraine symptoms.

Migraine Treatment During Menopause

If you are starting or transitioning into a later stage of menopause, be sure to work with your primary care provider and your headache specialist to find the right migraine management plan.

“It’s so important that we take an individualized approach to each and every one of you,” says Dr. Hutchinson. “And that approach may change depending on whether you’re perimenopausal, menopausal, and even whether you’re early versus late menopausal.”

When starting or changing hormone treatment, you and your doctor should monitor your migraine pattern as well as your mood. You can use a headache diary—either electronic or on paper—to track symptoms and note any changes. This will help your doctor make any necessary adjustments to your treatment plan and ensure that hormone treatments are not making your migraine or any other health conditions worse.

If you’re going through perimenopause or menopause, you can expect changes in your hormone levels that may affect your migraine. It’s important to remember that there are many options for migraine treatment during this time, even if that means adjusting a treatment plan that has always worked before. Talk to your doctor to find the right fit for your specific migraine and menopause symptoms.

The American Migraine Foundation is committed to improving the lives of those living with this debilitating disease. To learn more about all of your migraine treatment options, visit the AMF Resource Library. For help finding a healthcare provider, check out our Find a Doctor tool. Together, we are as relentless as migraine.