Sounds good. And quite reasonable. After all, between the ages of 15 and 45 migraine is roughly 3 times more common in females than males, and many females find that their migraine is exquisitely sensitive to fluctuations in their estrogen levels. It seems to follow that if these fluctuations cease, your migraine should cease as well. If your migraine typically acts up during the menstrual week, if you experienced a vacation from migraine during pregnancy, and if your mother, her mother, and even her mother experienced cessation of their migraine with menopause, then why not you as well? 

Well, as readers of this magazine know from previous articles involving migraine myths, the only consistent factor that can be claimed for migraine is its often infuriating inconsistency. In other words, nothing is ever “always” when it comes to migraine, either generally or, specifically, in predicting its clinical course. Migraine does not always involve severe headache…or pain that always is throbbing…or headache always preceded by aura…or always activate in association with menses. While some women experience migraine episodes only in association with their periods, others see no link whatsoever between their migraine and their menstrual cycle. Some unlucky women experience a dramatic worsening of their migraine during pregnancy. And then there is menopause.

There are certain times during a female’s life when migraine tends to activate. One is menarche/onset of puberty. The menstrual week and the first trimester of pregnancy are others. Less well known is the tendency for pre-existing episodic migraine to “transform” into the chronic variant (chronic migraine) during the perimenopausal years… especially those last few years preceding menopause.

While many females first began to experience migraine at menarche, others may exhibit symptoms related to migraine even as toddlers - at times these symptoms take the form of so-called migraine equivalents”: cyclical vomiting, vertigo, extreme motion-sickness, inexplicable abdominal pain. Other females may experience no hint of migraine until much later in life. The age of migraine onset for females is a bell curve that peaks at about age 20, and there are a substantial number of women whose migraine onset falls on the far side of that curve. 

Although it seems paradoxical for a disorder that so often possesses an obvious hormonal component, there are females who first begin to experience migraine following menopause. And just as the improvement in migraine that a female experiences with one pregnancy is not guaranteed to occur with subsequent pregnancies, so it is that the presence of a prominent family history of migraine ceasing with menopause does not ensure that you, too, will experience that same happy phenomenon.

That said, for most women (and men), migraine tends to wane during the later years of life. Interestingly, for that roughly 25% of the migraine population who experience aura at times, moving forward through their 50s and onward may bring a lessening of migraine headache but an amplification of migraine aura. It was Miller Fisher, one of America’s great stroke neurologists, who first described the phenomenon of “late life migraine accompaniments”, noting that these benign aura symptoms often could be mischaracterized as transient ischemic attacks (TIAs) indicating a high risk of imminent stroke.

Bottom line: aside from its inconsistency, nothing is ever “always” where migraine is concerned. Whether the result of the individual’s own particular genetic blueprint or the epigenetic changes to the genome that occur throughout life, changes that influence clinical expression of the blueprint, there are as many different paths that migraine may take as there are individuals afflicted by the disorder.

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