Migraine headaches can be frustrating to the women who endure them.
Often migraines lessen during menopause, but unfortunately, for many
women, this is not the case. Dr. Schulman articulates the issues facing
menopausal migraine sufferers as well as the treatment. — Beverly
Vaughn, MD, Medical Coordinator,Menopause and You
Migraine is primarily a disease of young, healthy women. Its onset often
coincides with the initial period and is triggered by the monthly menses
in over 60% of females. With this apparent hormonal factor, it is not
surprising that oftentimes the frequency and severity of migraine
decreases in menopause. A common belief is that migraine will lessen or
resolve after menopause. In most cases, this is true. Unfortunately, no
change or worsening has been observed in up to 50% of women. This is
especially true after surgical menopause, where over two thirds of
women's migraines worsen.
As a result of menopause, issues also arise that can affect the
treatment process. All patients who have migraines are generally treated
abortively (I have a headache. What do I take?). Patients may self-treat
using over-the-counter products such as Aleve or Excedrin Migraine.
Sometimes combination drugs such as Fioricet are used. Another group of
abortive medications, the triptans, is especially designed to treat the
pain of migraine, as well as its associated symptoms, including nausea
and sensitivity to light and sound. These medications include Imitrex,
Maxalt, Zomig, Frova, Amerge, Axert, Relpax, and Treximet. When
headaches are frequent or especially debilitating, the patient and
physician may agree to utilize prophylactic medication. These drugs,
Inderal and Topomax, as well as others, are generally taken daily to
HRT Effects on Migraines
Hormone replacement therapy (HRT) is widely used in menopausal females
to treat hot flashes and other common problems. In these menopausal
females, HRT may also prevent headache by stabilizing hormonal
fluctuations. Unfortunately, not all women respond to this treatment.
However, the results of the Women’s Health Initiative (2002), which
showed an increased risk of breast cancer, stroke and heart attack in
women using estrogen and progestin, the choice of whether to treat with
HRT is not clear. Additionally, migraine does carry a slightly increased
risk of stroke compared to patients without migraine. HRT itself is not
contraindicated in migrainous women, but it becomes a complex decision
based on the patient’s preferences and past medical history. The
decision to use HRT should be based on non-headache factors such as the
prevention of hot flashes. If headache becomes more frequent or
debilitating on HRT, the dose of hormones may be decreased or the dosing
schedule changed. Alternately, migraine preventive treatment may be
Abortive and Preventative Options
Triptans should be used as abortives unless there are absolute
contraindications. These include coronary artery disease or uncontrolled
hypertension. Also, risk factors for vascular events should be assessed.
Menopause and the aging patient are both a concern when deciding whether
a triptan is indicated. If these migraine-specific drugs are not an
option, an anti-inflammatory (such as Aleve), an antinausea drug, or
common analgesics are other options. Certainly, if headaches become more
severe or more frequent with menopause, or a triptan is contraindicated,
preventative medications should be considered. They fall into the broad
classes of antidepressants, anticonvulsants, calcium channel blockers,
and beta blockers. Each group has its own benefits. If possible, one
should try to treat two conditions with one drug. Mood disorders,
particularly anxiety and depression, are much more common in migraine
patients because of the deficiency of the neurotransmitter serotonin,
which is common to both disorders. In the migraine patient with
depression, an antidepressant may be the optimal way to treat both
conditions. Under no circumstances should a total hysterectomy be
proposed as a treatment for migraines. During perimenopause, when
hormone levels are fluctuating, headaches often become more severe and
frequent. These are particularly difficult to treat and preventive
medications may be a reasonable option.
Wellness should be a cornerstone of treatment for all patients. Wellness
includes taking good care of your body and your mind. Developing regular
sleep hours with adequate sleep time, eating healthy foods and not
skipping meals are key. An exercise program with input from your
physician is helpful in decreasing headache and relieving stress.
Carving out your own time is paramount for wellness. Vitamin B2 and
other natural substances may be helpful. Always make your physician
aware if you are taking nontraditional drugs as they may interact with
your more conventional medications.
Migraine in menopause may be a challenging condition at times, but there
are multiple options which are suitable for each patient after
addressing their medical conditions, lifestyle, and their own
preferences. Talk with your physician to learn what options are best for
This article is part of the Menopause and You library,
a Web-based program sponsored by Women’s Health Source.
It is intended as an information resource providing guidelines for
women. As always, check with your own healthcare practitioner with your
specific concerns and questions.
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