Migraine and the Perimenopause and Menopause
Migraine is a genetic, neurological condition affecting one in seven people but much more common in women than in men. Three times as many women than men have migraine and, in my clinic, I see many women struggling with migraine attacks especially in the perimenopause and menopause.
What is the reason for this higher frequency in women? The brain of a person with migraine is genetically set to be more sensitive to changes in their internal body environment and the environment externally. These epigenetic influences determine whether a person gets migraine attacks or not. This may vary greatly between relatives within the same family. Many people with migraine are affected by fluctuating blood sugar levels, erratic sleep patterns, increasing or decreasing stress levels and even changes in the weather or air quality but it is oestrogen levels varying during the perimenopause that make this a high-risk time for women to start having or experience worsening attacks.
Oestrogen levels fluctuate wildly during the years of perimenopause and even after the last period has finally finished. In women with migraine without aura, falling levels of oestrogen are a trigger for attacks. If aura is present, (meaning neurological symptoms -usually visual- which come and go within the hour before the headache phase starts,) rising levels of oestrogen can aggravate the brain and trigger attacks. Some women get migraine with and without aura in different attacks. It is also possible to have migraine aura, (flashing lights or zigzags or even blind spots in the visual fields,) but no headache at all. If you have new symptoms which you are concerned about, it is important to get the diagnosis confirmed by a doctor, preferably one with an interest in migraine. This may be your GP or a hospital neurology specialist.
There are many women who start having migraine attacks in their forties. Migraine is much more than just a headache. It is a diagnosis, not a symptom, and getting the correct diagnosis is so important for women to be able to manage these troublesome attacks. They may not realise that symptoms of troublesome headaches, neck and shoulder pain, facial or jaw pain, brain fog, dizziness, nausea and heightened sensitivity to light, sounds and smells which they experience are actually migraine. The diagnosis is often missed or dismissed as ‘stress’, ‘tension headaches’, or ‘just those headaches everyone gets’. Sinusitis is a common misdiagnosis too.
Women who have had migraine attacks for many years often comment that their attacks have become more severe, more frequent, last longer, and are harder to treat effectively. They may develop new symptoms too. Some women start getting intense dizziness as part of their attacks. Vestibular migraine is a subtype of migraine where dizziness is the most predominant feature and headache may be mild or absent. It can be managed as outlined below but vestibular physiotherapy may also be helpful in this type of migraine.
So, what can be done to manage migraine attacks during the perimenopause? Reducing and limiting change in your lifestyle is key. The brain of a person with migraine will be less likely to become triggered into an attack if a regular routine is established:
- Keep a migraine diary. This only needs to be simple but can help reveal any patterns or medication overuse contributing to the attacks. You can download one from the National Migraine Centre website.
- Eat something every 3-4 hours, preferably low carb, slow-release energy foods. Never skip meals and consider adding a bedtime snack. Keep a healthy gut microbiome by eating 30 different plant-based foods weekly – vegetables, pulses, nuts, seeds, herbs, spices etc.
- Be careful with caffeine -keep to 1-2 cups daily, change to decaffeinated after lunch.
- Try and keep a regular sleep routine. Fix your morning wake -up time and get out into daylight early to help your body’s circadian rhythm. This helps sleep quantity and quality.
- Try to do mild to moderate exercise regularly. Intense exercise can be triggering. Eat before and after exercise and stay hydrated.
- Consider specific vitamin and mineral supplements which have been found to be helpful – Magnesium, Vitamin B2, and Co enzyme Q 10.
- Recent studies highlighted the importance of Vitamin D and Omega 3 for reducing migraine frequency. All these supplements need to be taken for at least three months.
- Reducing stress can help. There are various techniques to do this including mindfulness meditation, writing out feelings, yoga, Tai chi, or simple breathing exercises. Choose a destressing regime that suits your daily routine and practise it regularly.
Hormone replacement therapy can be very helpful as a preventive for women with migraine. There is no problem about taking HRT even if aura is present assuming you have no other contraindications. HRT preferably needs to be of the transdermal type, so I advise oestrogen patches which smooth out oestrogen fluctuations by continuous absorption through the skin. Patches are changed twice a week and some women are sensitive to the changeover time so make sure you replace the patch every 3.5 days to maintain that smooth blood level of oestrogen. Gels and sprays of oestrogen can be used if patches don’t suit but it is generally better to avoid the daily oral tablet form as this can give swings in blood levels of oestrogen. The benefits of HRT generally far outweigh the negatives and modern body-identical hormones are much safer than the ones used in past decades.
A woman who still has a uterus will also need to take progesterone in some form -either via a Mirena coil or Utrogestan tablet- to protect the lining of the womb from building up. Your GP or Menopause specialist clinic can advise on this.
Other preventive medications, injections and neuro-modulation devices may be useful if taking HRT is not possible. The preventive treatments include many different medications taken by mouth which have been prescribed by doctors for years to prevent migraine. They are all borrowed from other conditions: anti-depressants, anti-epileptic, anti-hypertensives have all been found to be useful in some people. The aim is to find the right one for each individual and this can be a frustratingly slow process of trial and error. Generally, the advice is to take a preventer in the maximum tolerated dose for at least three months before assessing its efficacy for you. Side effects can be a nuisance but don’t affect everyone.
There are three types of injection therapies used for frequent migraine: Greater Occipital nerve blocks, Botox and the new anti-CGRP monoclonal antibody injections. These are all approved by NICE and may be available at your local Headache specialist clinic. There are strict criteria for having these on the NHS.
Neuro-modulation devices like the Cefaly Dual device can help too. They can be used as preventives or to help manage an acute attack. They are safe and often well-tolerated so can be an option if you don’t want to take tablets. Acupuncture helps some women too.
For acute attacks, the goal is to take the right medication, at the right time and have it in the right place in your gut. I think of a migraine attack as a snowball rolling and gathering momentum -it’s best to squash it hard and fast to stop it impacting on you. The migrainous process occurring in the brain affects the vagus nerve and slows gut motility. This results in nausea and vomiting sometimes but also slows down absorption of painkillers. This allows the migraine attack to build up. An anti-sickness tablet prescribed by your doctor can really help at the beginning of an attack and there are several options available. Add a painkiller such as Ibuprofen, Naproxen or Soluble Aspirin (but never opiates like Codeine) and a migraine specific medication, a triptan, in combination to quickly abort an attack. There are seven different triptans and one may suit even though another did not, so it is worth working out which one is best for you. Some people find a sugary, fizzy drink at the beginning is helpful too (not usually recommended as a health food but can be useful in this specific situation). Beware of taking any painkillers or triptans on more than 10 days per month as this may aggravate migraine.
Migraine attacks tend to reduce in frequency and severity past the menopause. HRT can be continued for as long as a woman chooses providing that there is no additional contraindication, and many women find they feel so much better on it.
Finally, a word about children. Migraine is a genetic condition so keep it in mind if children have any recurrent attacks of headache, dizziness, nausea and vomiting or abdominal pain. In young children, headache may be absent, and the migraine attack is largely felt in the abdomen. The child may look pale and be yawning or very fatigued too. A peak time to have attacks is during puberty when so many changes in hormones, growth and life stresses affect young people.
Migraine needs to be better recognised by society as the debilitating condition that it is. When it is chronic and impacting a person’s life severely it is classed as a disability under the Equality Act and employers are required to take this into consideration when a women is absent due to migraine. More investment in research and headache specialist training is urgently needed. There is a lot of help available for this common, misunderstood invisible illness. Understanding what is happening is essential for getting the right help for you and your migraine.
Dr Katy Munro worked as a GP in the NHS for over 25 years. She has had a long-standing interest in migraine & chronic pain. She now works as a Headache Specialist for the National Migraine Centre, a charity providing specialist doctor appointments & information about headache disorders. She hosts their podcast, Heads Up. In August 2021, her book, ‘Managing Your Migraine’ was published as part of the Penguin Life Experts series. She has spoken about migraine on TV, Radio, guested on other podcasts and written many articles to raise awareness.