“The migraine brain likes what we call homeostasis; it doesn’t like a lot of change,” says Roderick Spears, MD, a neurologist and headache expert at Penn Medicine in Philadelphia. When there are changes — whether those are external, like weather changes, or internal, such as changes in diet, sleep, or hormones — it can trigger an attack, he says. For many women, fluctuations in estrogen levels can trigger migraine attacks. About 60 percent of women with migraine experience attacks related to their menstrual cycle, according to the National Headache Foundation. Perimenopause, the months- or years-long transition leading up to menopause, is a time of lots of changes that are often a result of fluctuating hormone levels, especially in the hormone estrogen, according to the North American Menopause Society. After menopause, defined as the time when a woman has gone 12 consecutive months without a period, according to the National Institute on Aging, hormone levels, including estrogen levels, are much more stable. “I would say about 70 percent of women see some improvement after the menopause transition,” says Dr. Mays. But getting there can be hard for some women, she says. “Perimenopause can be a very difficult time, because hormones are changing and fluctuating so much. In that phase, someone might have two menstrual cycles in a month or continuous bleeding. Things like that may be triggering headaches,” says Mays. The risk of high-frequency headache, or more than 10 days with headache per month, increased by 60 percent in middle-aged women with migraine during perimenopause, according to a study published in January 2016 in Headache: The Journal of Head and Face Pain.
Can Menopause Cause Migraine?
A small number of women may develop headaches for the first time around the time of menopause, and some women with an existing headache disorder may find their headaches worsen, says Mays. Every woman is different, and it isn’t clear why some women experience migraine for the first time during perimenopause, though it’s likely connected to hormone fluctuations, according to the North American Menopause Society. On the positive side, hormonal migraine typically goes away after menopause when estrogen surges stop and levels are consistently low. Menopause can cause other types of changes in migraine, says Mays. “For example, some women can develop migraine aura, but they don’t get the headache with it. They’ll get flashes, the lights, or zigzag lines when they’ve never had it before,” says Mays. In migraine with aura, a person experiences visual disturbances, which may include spots, geometric patterns, flashes of light, or temporary vision loss; sensory disturbances, such as numbness or tingling in the limbs or face; limb weakness; speech problems; or aural symptoms, in which a person hears noises or music. “Similarly, there are also are some women who have had migraine with aura before, and then they stop having the headache portion of it,” Mays says. “It can be worrisome for patients if these focal neurologic deficits appear for the first time in older age, and in some cases, investigation with imaging is necessary to rule out potential causes other than migraine,” says Mays. “Sometimes I try to get my patients who have been pregnant to think back and remember if they had migraine attacks during pregnancy or if they improved,” she says. “In some cases, if a woman has improvement of migraine during pregnancy, it may be more likely that it will improve during menopause as well, though that’s not true 100 percent of the time,” says Mays. Women who undergo surgical menopause often have their migraines get worse, says Mays. “It’s very tricky, and I definitely don’t recommend that women have their ovaries removed as a way to improve migraine, because the majority of the time, it doesn’t happen,” she says. “Although it seems like it would be easy to do some hormonal manipulation to try to control migraine, that isn’t the case,” says Mays. “There have been various studies to look at this, but there doesn’t seem to be a tried-and-true method that works for everyone,” she says. Some symptoms of menopause may worsen migraine, says Mays. For example, interrupted sleep is a common menopause symptom, and poor sleep can be a trigger for migraine, according to the American Migraine Foundation.
What Kind of Migraine Improves After Menopause?
There are a few kinds of migraine that are more likely to improve after menopause, says Mays. “Women with migraine without aura and menstrual or menstrually related migraine often find their headaches get better,” she says. Even outside the context of menopause, there is a gradual decline in migraine with aging, says Mays. “In women, the peak of migraine prevalence is between ages 25 and 45; after that we start to see a decline. Although we certainly can attribute some of that to declining estrogen levels, we see migraine prevalence going down in men as they age, too,” she says. It’s also common that as people with migraine get older, they lose some of their symptoms, says Mays. “In general, they don’t have as much light sensitivity, sound sensitivity, nausea, or vomiting,” she says. Because of these changes, people sometimes think that they’re developing more tension-type headaches, but this isn’t the case, says Mays. “It’s really that their migraine has modified over time, and some of the most bothersome symptoms aren’t as bothersome as they get older,” she says.
What Helps With Menopausal Migraines?
Evidence suggests that regular exercise and following a healthy diet can reduce the frequency of migraine attacks, according to the American Migraine Foundation. Maintaining a healthy weight in menopause may help improve migraine; the risk of migraine increases with obesity status — from healthy weight to overweight to obese, according the American Migraine Foundation. There is also evidence that complementary therapies such as relaxation, biofeedback, and cognitive behavioral therapy may help improve migraine, according to the American Headache Society. Research published in the journal Headache in September 2019 found that a mindfulness-based intervention helped reduce disability and the negative impact of migraine. Triptans are often a go-to medicine to treat migraine symptoms, but they may not be appropriate as people get older, according to Mays. Those medications should not be used by people who have a past history or risk factors for heart disease, high blood pressure, high cholesterol, angina, peripheral vascular disease, impaired liver function, stroke, or diabetes, according to the National Headache Foundation. If triptans didn’t work for you or if you can no longer take them, there are new medications for acute migraine, known as gepants and ditans. “These drugs don’t constrict the blood vessels,” says Mays. Gepants are CGRP receptor antagonists; there are currently two approved medications in this class: Nurtec ODT (rimegepant) and Ubrelvy (ubrogepant). Reyvow (lasmiditan) is a ditan, and it works on a type of serotonin receptor found on nerves, according to the American Headache Society. Nonsteroidal anti-inflammatory drugs should be used with caution, especially by older adults, says Mays. “Kidney disease is more common as people get older, and so you want to be careful if you’ve been taking a lot of ibuprofen for migraine,” she says. It’s generally advised that people with chronic kidney disease avoid NSAIDs with the exception of aspirin, according to the Centers for Disease Control and Prevention (CDC). “If your migraines do improve with menopause, you may want to consider decreasing some of the preventive therapies that you are taking,” says Mays. Often people need to add on additional medications for chronic conditions as they get older, and so it’s a good idea to review and eliminate medications that you no longer need, she says. “This can help avoid polypharmacy,” she adds. Polypharmacy is the use of more medications than are medically necessary. Eliminating or tapering migraine medications should be something you discuss with your doctor before you make any changes, says Mays. Additional reporting by Katherine Lee.
