Migraine & Menopause 

Whilst much attention is focussed on perimenopause symptoms like hot flushes, night sweats, anxiety and disturbed sleep; migraines are a common but often under-reported condition in perimenopausal and menopausal women, yet up to 30% of women going through the menopause have migraines and around 75% have headaches.¹

Migraine is three times more common in women than in men and is often linked to the menstrual cycle.² Fluctuating hormone levels often trigger migraines. Some women find that the natural drop in oestrogen which happens around menstruation can trigger migraine. As the menstrual cycle becomes more erratic (typically around the age of 40-45), oestrogen levels become increasingly variable, often increasing the likelihood of migraine.

Symptoms of migraine

Although migraine symptoms and severity may vary, the classic signs include a throbbing headache (usually on one side of the head, although not always), nausea, sickness, blurred vision, seeing flashing lights, extra sensitivity to light, sound and smells; and fatigue. The throbbing pain may be so severe that any sort of movement feels impossible.  Attacks typically last anything from three hours to three days.

Some women have an ‘aura’ which is a warning sign of an impending migraine. An aura is often visual and affects sight in the form of blind spots or flashing lights. It may last for up to an hour, before other migraine symptoms begin to occur. About one in three women have migraine with an aura.

Impact of migraine

Migraine can have a severe impact on life. Some women have chronic migraine – migraine for 15 days or more a month, meaning that half their life is spent in pain and being unable to function normally. It can be very disabling and negatively impact on home, work and social life. Often, lying down in a dark room is the only way to cope with the overwhelming symptoms.

In a survey of women attending a specialist menopause clinic, migraine affected 42 percent of women and a fifth reported having a headache every single day. These migraine attacks were associated with significant disability with 78 percent of women reporting very severe or substantial disability.³

Migraine Trust research found that 60 percent of people with migraine feel it had significantly impacted on their relationship with their partner and 71percent reported an impact on their mental health.⁴

Treatment

Currently there is no cure for migraine, but it can be managed. The right treatment depends on the type of migraine, and the frequency and severity of attacks.

Hormone Replacement Therapy (HRT)

Many women notice that migraine is more likely to occur when they have severe hot flushes and night sweats. Since HRT is effective at controlling these menopausal symptoms, it can help reduce the likelihood of migraine.

However, some women find that HRT exacerbates migraine and creates more hormonal fluctuations. In this case oestrogen gels or patches may be preferred to tablets, as they are more likely to maintain stable hormone levels. The benefits of HRT on relieving menopause symptoms need to be balanced with the potential effect on migraine.

Over-the-counter (OTC) analgesics

OTC analgesics are used to treat the pain of a migraine attack and includes paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen. Painkillers that contain opioids like codeine are best avoided in migraine as their benefits may be short-lived and they can be addictive.

There is a risk of OTC analgesics causing medication overuse headaches and it is best to keep the use of the medications to twice a week or less. (see below).

Triptans

Triptan are an alternative medication if OTC analgesia is not relieving migraine pain. Triptans (also known as 5-HT1 agonists) help ease the symptoms of a migraine attack. Most triptans need to be prescribed, apart from sumatriptan which can be bought in a pharmacy. They are not analgesics, but imitate a brain chemical called 5-hydroxytryptamine (5-HT), which is also known as serotonin.

Anti-emetics

Anti-emetics are used to treat sickness (nausea and vomiting) during a migraine attack. They should be taken before or at the same time as any analgesics which are being taken. Some anti-emetics can help your body absorb analgesics.

Preventive medicines (prophylactics)

These are taken every day and help to prevent or reduce the severity and frequency of migraine attacks. There are a number of different drugs which may be prescribed to help prevent migraines.

They are usually prescribed if at least four migraines a month are being experienced. It may take 6-8 weeks for preventive treatment to start making a difference. The most commonly used migraine preventatives are propranolol and amitriptyline. If a migraine attack occurs, you can still take painkillers or a triptan in addition to the preventive medicine.

CGRP monoclonal antibodies

Calcitonin gene-related peptide antibodies (CGRP) monoclonal antibodies (mAbs) are a new type of treatment for migraine. They are the first preventive medicines specifically developed for the treatment of migraine. During a migraine attack the cerebral nerves and blood vessels release substances including CGRP. This is known to be involved in the brain processes which cause pain during an attack.

The new drugs target CGRP to prevent migraine developing. They are taken by injection, either monthly or every few months but they are not widely available in the UK at present and other preventative drugs needs to be tried first.

Medication Overuse Headache

The regular high-level use of painkillers increases the risk of medication overuse headache. When this happens, pain returns as each dose of analgesia wears off.  Even if the medicine is stopped, withdrawal symptoms are common. The need to relieve these withdrawal symptoms, and still treat the pain, leads to further use of analgesia and a cycle of medicine overuse starts. Eventually the painkillers stop helping the original pain and start causing more pain.

Lifestyle

A number of trigger factors may contribute towards a migraine attack, like stress and changes in the menstrual cycle, particularly leading up to menopause. However, it is not always easy to identify which triggers potentially lead to a migraine. Therefore keeping a daily diary may help to identify your particular triggers.

Sleep patterns, diet, exercise and stress may all contribute. Lifestyle strategies including regular exercise, maintaining a normal body weight and talking therapies such as cognitive behavioural therapy, have all been shown to be effective for both migraine and menopause symptoms.

Taking food supplements like riboflavin, vitamin B2 and magnesium may all be beneficial to women in the perimenopause and menopause.

Following menopause, migraine becomes less of a problem, particularly in women who have noticed a strong link between migraine and hormonal triggers.

Useful Resources

www.womens-health-concern.org
www.menopausematters.co.uk 
www.managemymenopause.co.uk 

References

1. MacGregor EA, Migraine, the menopause and hormone replacement therapy: a clinical review J Fam Plann Reprod Health Care 2007; 33(4): 245–249

2. Pavlović JM Evaluation and management of migraine in midlife women Menopause. 2018 August; 25(8): 927–929

3. MacGregor EA, Migraine and Perimenopause, 2022 https://migrainetrust.org/news/migraine-and-perimenopause/ accessed 13th October 2023

4. Migraine Trust Research. https://migrainetrust.org/understand-migraine/impact-of-migraine/ accessed 13th October 2023