Headaches affect over 90% of women at some point during the perimenopause, which is the time preceding the end of your periods. Hormonal changes tend to affect the incidence of migraine, while increased stress during this time can trigger tension headaches. Menopausal bone pain can lead to neck pain-related headaches, and headaches can be a feature of many ageing-related long-term conditions. Carefully managing osteoarthritis, osteoporosis, diabetes, kidney disease and thyroid imbalances will help to minimise non-hormonal headache occurrence and severity.

This article was included in issue 98 (Autumn 2023) of The Menopause Exchange newsletter

Migraine changes
Migraine tends to worsen in the years leading up to the menopause, with attacks becoming more frequent and long-lasting. This is mostly due to fluctuating oestrogen levels, like the initial worsening of migraine at puberty. As the menstrual cycle becomes more erratic from the early-40s, periods can be more troublesome, with more pain and heavier bleeding. Many women notice a link with their periods as these become erratic.

Following the menopause, women may find migraine becomes less of a problem, particularly if they previously noticed a strong link between migraine and hormonal triggers. As periods lessen, the hormonal triggers for migraine also lessen. It may take several years for migraine to improve, because it can take this long for hormonal fluctuations to settle. After the menopause, non-hormonal migraine triggers will persist, so if these are important factors, attacks will still continue.

HRT effects
Some women associate their migraines with bad hot flushes and night sweats. HRT can be effective at controlling these so may also help to reduce the incidence of migraine. Conversely, some forms of HRT, especially tablets, may create more hormone fluctuations, triggering migraine. Women with migraine wanting to try HRT may benefit from using oestrogen patches or gel, which tend to maintain more stable hormone levels with fewer fluctuations. The best oestrogen dose is one that’s just sufficient to control hot flushes – it can take three months before the full benefit is achieved.

Vaginal oestrogen can help to control local discomfort and dryness but may cause a temporary increase in migraine during the first couple of weeks. This quickly settles, with no evidence that vaginal oestrogen triggers migraines with long-term use.

Unless you’ve had a hysterectomy, you’ll also need progestogens to protect your womb lining from oestrogen-response thickening. Progestogen is combined with oestrogen in tablets or patches, or separately either as tablets or within intrauterine systems such as Mirena (‘IUS’, ‘coil & progesterone’).

The IUS is useful for contraception, to control heavy or painful periods, and to act as the progestogen component of HRT. Another advantage is that it acts directly on the womb, minimising circulating hormone levels and associated side-effects. It’s then easy to adjust the dose of oestrogen to suit your needs. The IUS often reduces or stops period loss; if migraines were linked to troublesome periods, it can make migraine less likely to occur.

Unlike the combined oral contraceptive pill, which isn’t suitable for women with migraine aura, HRT containing natural oestrogen produces similar levels to the oestrogen made by your body during your menstrual cycle. If your migraine aura worsens or starts for the first time with HRT, it’s usually because the dose of oestrogen is more than you need.

Non-hormonal medication alternatives to HRT include escitalopram or venlafaxine. These act on the chemical messenger serotonin, which is implicated in both migraine and hot flushes.

Impact of hysterectomy
Research suggests that hysterectomy may worsen migraine. Your menstrual cycle is controlled by your brain, sending messages to your ovaries to stimulate oestrogen and progesterone production. If your womb and ovaries are removed, this hormone cycle is disrupted. Your brain hormones initially go into ‘overdrive’ as they’re not prepared for this ‘early menopause’. Migraine can worsen but generally settles again over the subsequent couple of years.

Replacement oestrogen may help to ease migraine symptoms following hysterectomy, particularly if your ovaries were removed. Even when your ovaries are retained, the natural hormone cycle can be disrupted, so additional oestrogen may help.

Seeking help
Your local pharmacist can advise about headache management, including taking painkillers such as paracetamol and anti-inflammatory medicines such as ibuprofen, either as tablets or topical gels. Complementary therapies that may help migraine include massage, local heat pads, relaxation therapies, acupuncture, psychotherapy and hypnotherapy.

If your migraines worsen at the perimenopause or later, see your GP. They will look at your general health and migraine triggers, considering treatments for both your menopausal symptoms and migraines. Maintaining good migraine ‘habits’ – regular meals, regular exercise, a good sleep routine and looking after your general health are all as important after the menopause as before. If you’re overweight, weight loss can benefit both migraine and menopause symptoms, along with regular exercise.

Medical management includes the recognition and management of triggers and taking painkillers and specific migraine therapies, such as triptan tablets, nasal sprays or injections. If these don’t help, ask your GP about referral for specialist treatments, including Botox (Botulinium toxin) and monoclonal antibody injections.

About the author
Dr Gill Jenkins is a GP and medical writer in the west of England with particular interest in women’s health, diabetes and travel medicine. She works for an air ambulance company, repatriating patients taken ill abroad.

Created Autumn 2023
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Tags: GP, headaches, HRT, hysterectomy, menopause, migraine, oestrogen, perimenopause, progestogen