Migraine, menopause and HRT

Why menopause can be a real headache – and what to do about it

Most women will experience migraine during menopause. Our factsheet helps you navigate your journey and minimise the impact of troublesome symptoms.

What is the menopause?

In strictly medical terms, ʻmenopauseʼ refers to a woman’s last natural period and technically can be confirmed 12 months after periods end. But it’s more generally used to describe the time in life when periods become less regular and other symptoms, like hot flushes, occur.

These symptoms result from changes in the ovaries that can start around ten years before a woman’s last menstrual period. So, the term perimenopause is used to refer to this transitional period before menopause.

Headache with menopause is very common.

What is likely to happen as I approach and pass through the menopause?

Migraine and menopause are closely associated. Perimenopausal migraine, where migraine symptoms worsen in the years leading up to the menopause, is often characterised by attacks which occur more frequently and sometimes also last longer.

In the early stages of menopause, when periods become erratic and more frequent, so do migraine attacks. Towards the end of menopause, as periods become less frequent, migraines will also lessen.

For women who have noticed a strong link between migraine and hormonal triggers, post-menopause can be a blessing as migraine is very likely to improve. This may take two or three years after the last period, as it can take this long for the hormones to settle. Non-hormonal triggers can still persist after menopause so if these are important causes for migraine, attacks will still continue.

Migraine symptoms in menopause are otherwise similar to other stages of life and migraine treatment during menopause will also generally follow the same basic guidelines outlined elsewhere in our other factsheets.

What happens during the menopause that causes migraine to worsen?

The main reason for worsening migraine during menopause is the fluctuation of oestrogen. This is also responsible for initial worsening of migraine at puberty, as it can take a few years for the hormones to reach the settled pattern of the menstrual cycle.

From late teens to the mid 30s, most women have a regular pattern of menstrual cycle hormones.

For some women, the drop in oestrogen that occurs naturally around menstruation – and which is artificially-induced during the pill-free week of oral contraception – can trigger attacks.

Others find that heavy, painful periods are linked to migraine.

From around the early 40s, the menstrual cycle can become more erratic, with much more variable fluctuation in oestrogen levels. Periods themselves can be more troublesome, with more pain and heavier bleeding. All these factors can make migraine more likely.

As periods lessen, so do the hormonal trigger for migraine, which is why many women find migraine improves after the menopause.

Migraine and HRT

HRT should not be used as a treatment for migraine. However, many women notice that migraine is more likely to occur when they have bad hot flushes and night sweats. Since HRT is very effective at controlling these menopause symptoms, it can help reduce the likelihood of migraine.

Our doctors are often asked what the best form of HRT is those with migraine. Some forms of HRT can create more hormone fluctuations, which can actually trigger migraine. This is more likely to occur with HRT tablets and it is generally recommended that women with migraine who need HRT should use transdermal types, such as oestrogen patches, gels or sprays, as these maintain stable hormone levels with few fluctuations.

The best dose of oestrogen is the lowest dose necessary to control flushes and sweats. This may be as little as 25mcg with oestrogen patches, or one pump of oestrogen gel. Try this for six weeks and if flushes persist, increase to 50mcg patches, or two pumps of gel.

Bear in mind that it can take three months before the full benefit is achieved, so don’t increase the dose too quickly.

Some women do need higher doses of up to 100mcg patches or four pumps of gel, but this can usually be reduced once the symptoms settle.

Unless a woman has had a hysterectomy, she will also need progestogens to protect the lining of the womb from thickening in response to oestrogen. If this goes unchecked, it can potentially lead to cancers many years later. Women with migraine best tolerate progestogens when combined with oestrogen in patches, capsules of micronised progesterone or the Mirena intrauterine system.

Can you use the Mirena coil as well as HRT?

The Mirena intrauterine system (ʻthe hormonal coilʼ) can be used for contraception, to control heavy or painful periods, and to act as the progestogen component of HRT.

One advantage is that it acts directly on the womb, with very little hormone reaching the rest of the body. This means that side effects are generally very few.

Another advantage is that if a woman has a Mirena, it is easy to adjust the dose of oestrogen to suit her needs.

Also, many women find that their periods become very light, or stop completely while they are using a Mirena. So, if migraine was linked to troublesome periods, this in itself can make migraine less likely to occur.

When should I stop migraine prevention treatment following menopause?

The usual recommendation is that the effective dose of medication used for migraine prevention should be continued for around six months. The dose should then be slowly reduced, which may be over two to three months.

If migraine returns after a drop in dose, then the dose should be increased again to effectively control attacks for a further few weeks before trying a dose drop again. This helps find the lowest effective dose to control migraine and enables you to find out how long you actually need to stay on treatment.

Why do I still get migraine even though I’m through the menopause?

Even though your periods have stopped, it can take a few years for the hormone fluctuations to completely settle. This is usually just one or two years, although some women find that they still get hot flushes and migraine ten or more years after the menopause.

More often, even when hormonal triggers have settled, non-hormonal ones persist and may even increase post menopause.

Chronic medical conditions, while not directly triggering migraine, will make migraine more likely to occur as they generally lower the migraine threshold.

Maintaining good ‘migraine habits’, such as regular meals, regular exercise, a good sleep routine, balancing triggers and looking after your general health, are all as important after the menopause as before.

Why does hysterectomy often make migraine worse?

All research points to the fact that hysterectomy worsens migraine.

The menstrual cycle is controlled by the brain, which sends messages to the ovaries to stimulate the production of the hormones oestrogen and progesterone. These in turn prepare the lining of the womb for a potential pregnancy. If a woman does not become pregnant, then the lining of the womb is shed at menstruation and the cycle starts over again.

If the womb and ovaries are removed, the hormone cycle is disrupted, and the brain hormones initially go into overdrive as they are not prepared for this early menopause. Migraine initially worsens but generally settles again over the subsequent couple of years.

Replacement oestrogen can help lessen the symptoms following hysterectomy, particularly if the ovaries have been removed. Even when the ovaries are retained, the natural hormone cycle can be disrupted, so additional oestrogen may be helpful.

Vaginal oestrogen made migraine worse – what next?

Vaginal oestrogen is useful to help control local symptoms of pain and dryness in women who have no problems with hot flushes or sweats, or who still get vaginal symptoms despite using HRT.

When a woman first starts to use vaginal oestrogens, a rise in oestrogen has been measured in the blood stream. Higher levels persist for a couple of weeks and then drop back down. This rise and fall can be sufficient to trigger migraine in susceptible women.

With continued use of vaginal oestrogens, usually only necessary just once or twice a week, oestrogen levels settle and are less likely to trigger migraine.

Don’t be put off trying vaginal oestrogens but do be prepared for an initial increase in migraine.

If migraine does not settle then an alternative treatment needs to be considered, which will depend on what the initial symptoms were. If vaginal dryness was the main problem, then a lubricating gel is a non-hormonal alternative.

Book an appointment with the experts: a consultation with a leading headache specialist, with an understanding of women’s health, migraine and menopause, could help you get on top of migraine. Book your consultation now.