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Migraine in menopause

Lankenau Medical Center October 14, 2009 By Elliott Schulman, MD

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. Elliott Schulman articulates the issues facing menopausal migraine sufferers as well as the treatment. – Beverly Vaughn, MD, Medical Coordinator, Menopause and You Program

Hormonal influence

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 percent 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 Topamax, as well as others, are generally taken daily to prevent headaches.

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 instituted.

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 anti-nausea 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.

Everyday tips

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 you.

This article is part of Menopause and You, 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 health care provider with your specific concerns and questions.

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