Navigating Perimenopause/ Menopause with Migraines: The Highs and the Lows
Between the ages of 15 and 45 migraine is roughly 3 times more prevalent in females than males. Prior to puberty and following menopause this disparity is less apparent, and it’s entirely possible that the genetic predisposition for migraine is just as common in males as in females.
So then what accounts for this the disparity in migraine prevalence during the childbearing years? In a woman’s life, migraine tends to emerge or, if already present, worsen at several distinct times: menarche/onset of puberty, menses, the first trimester of pregnancy, the period immediately following childbirth and perimenopause/early menopause. Common to all of these times is an often dramatic fluctuation in the levels of sex hormones and in the level of estrogen in particular. Put another way, women may have no more of a genetic predisposition to migraine than men, but consequent to these hormonal fluctuations they are more likely to clinically express that genetic predisposition.
While for many women menopause may bring with it a dramatic reduction in migraine burden or even cessation of migraine, recall once again that the only “always“ in migraine is that nothing about migraine is ever “always”. There are women who may experience a significant worsening of migraine with perimenopause/menopause, and there are even women who first begin to experience migraine after the onset of menopause.
Regardless, in the 20 issues of this magazine published to date we have devoted many pages to migraine and pregnancy and to menstrual migraine, but we have offered readers relatively less information regarding the impact of perimenopause/early menopause on migraine. With the help of our invited contributor who has much experience in this area, Ms. Caroline Stowe, we will begin our attempt to correct this deficiency.
For individuals experiencing migraines, the journey through perimenopause and menopause can present unique challenges. The hormonal fluctuations during this phase of life often influence the frequency, intensity, and patterns of migraine, making these years a significant challenge to navigate even for those already veterans of dealing with these debilitating headaches.
Several renowned figures have spoken candidly about their struggles with menopause and the challenges posed by migraine during this phase of life. Here are two:
Michelle Obama The former First Lady has shared her experiences with menopause, highlighting its impact on both physical and emotional well-being. She addressed the changes in her body, emphasizing how her migraine episodes became more frequent and intense during menopause.
Gwyneth Paltrow Known for her holistic lifestyle approach, Paltrow has openly discussed her menopausal symptoms. She has emphasized the importance of seeking therapies that will reduce the impact of menopause on one’s daily life.
Understanding Perimenopause and Menopause
Perimenopause marks the transitional phase before menopause and is characterized by hormonal fluctuations and irregular menstrual cycles. As estrogen and progesterone levels fluctuate, these changes can trigger migraines in those who are predisposed. Menopause, defined as the cessation of menstrual periods for 12 consecutive months, occurs around the age of 51 on average, but the hormonal changes can begin earlier, during perimenopause. Naomi Watts recently spoke out about her experience with perimenopause and migraine, emphasizing how she felt very alone during that time and how much better she might have felt if perimenopause was a more prominent public topic.
Impact on Migraine
Hormonal fluctuations play a pivotal role in triggeringigraine. Estrogen is known to affect neurotransmitters, blood vessels, and pain perception, all which can influence the experience of migraine. During perimenopause and menopause, the erratic hormone levels may lead to increased migraine frequency, increased headache severity or other changes in migraine symptomatology for some.
Positive Aspects of Perimenopause/Menopause for Migraine Sufferers
Reduced Frequency Some (but definitely not all) lucky women experience a reduction in migraine frequency or intensity during menopause. This is attributed to the stabilization of hormone levels that occurs post-menopause, providing welcome relief for those migraineurs who have suffered from the disorder for much of their lives.
Freedom from Menstrual Migraines Women who regularly have experienced menstrual migraine often find welcome relief as their periods cease during menopause. For them, the absence of the hormonal fluctuations associated with menstruation removes that unhappy headache week from their monthly calendars.
Potential Treatment Options Healthcare providers may suggest hormone replacement therapy (HRT) or other medications to manage menopausal symptoms for qualifying candidates who do not have contraindications for HRT. These treatments can affect migraine positively or negatively, and their use requires careful consideration and subsequent monitoring by your healthcare provider.
In May of this year, the FDA approved the first non-hormonal drug to ease menopause hot flashes. The new pill, called Veozah (fezolinetant), is from a class of drugs called neurokinin 3 (NK3) receptor antagonists. This is exciting as women who experience migraines are more likely to experience vasomotor symptoms during menopause.
Challenges
Change in Migraine/Change in Treatment
What therapies that have “always” worked for your migraine may not work as well during menopause. There are both preventive and abortive treatments appropriate for use in cases of post-menopausal migraine, and the number of monthly headache days you are experiencing, the intensity of your headaches, your associated migraine symptoms and your medical history will influence the management plan you and your healthcare provider develop.
Regardless, I tell each such patient that there’s light at the end of the tunnel. Approximately 70% of patients will experience a decline in their migraine burden as they settle into menopause.Increased Migraine Frequency
For many, perimenopause can be a period of heightened migraine activity due to hormonal fluctuations. This can be frustrating and challenging to manage alongside other menopausal symptoms, and it may be time for a course of prevention therapy to stabilize your migraine and reduce headache burden.
HRT and Migraines
Hormone replacement therapy, while helpful for managing menopausal symptoms, can sometimes exacerbate migraine. Finding the right type, dose and preparation of HRT requires consultation with a knowledgable and sympathetic healthcare provider.Altered Migraine Pattern
Some individuals may notice changes in their typical migraine pattern during menopause. This shift may involve different triggers or new symptoms, and amongst the new symptoms many women experience is the first emergence of aura (most commonly visual) or, more often, resurgence of aura after its absence for many years. Benign aura symptoms may be misinterpreted by patients and clinicians as “mini-strokes”, a diagnostic wrong turn that can produce much unnecessary anxiety and expense.
Coping Strategies and Management:
Healthy Lifestyle Prioritize regular exercise, balanced nutrition, adequate sleep, stress management, and hydration to help manage migraines during this phase. There is very little more important to brain health than regular exercise.
Track and Monitor Keeping a migraine diary can help identify triggers and patterns specific to perimenopause/menopause, aiding in the development of management strategies tailored to your specific needs.
Consult Healthcare Providers Seek guidance from healthcare professionals with experience in managing both migraine and menopause so as to construct a “customized” management plan.
Conclusion
Perimenopause and menopause can significantly impact individuals already dealing with migraine, bringing some relief and others new challenges. Understanding the hormonal shifts that are occurring and how they influence migraine can empower you to seek, find and implement an effective management strategy so as to navigate this transitional phase with more comfort and control.
Resources for learning more:
https://www.fda.gov/consumers/womens-health-topics/menopause
https://americanmigrainefoundation.org/resource-library/migraine-and-menopause-webinar-recap/
https://www.migrainedisorders.org/education/patient-resources/
https://drsusanhutchinson.com/books/
Caroline Stowex
The author, Caroline Stowe, DNP, MSN, FNP-BC, AAHIVS, AQH, MSCP, trained at the College of Charleston, the Johns Hopkins University, and George Mason University. She has been practicing as a family nurse practitioner for over 14 years and has a specific interests in telemedicine, primary headache disorders and sexual/reproductive health, including menopause. Ms. Stowe is a member of the faculty at the George Mason University School of Nursing in the MSN-FNP program and lives in Fairfax, VA with her husband and 2 children.