Migraines and Menopause: Why Hormones Can Be a Headache
For many women, migraines are more than just a painful inconvenience, they’re a recurring disruption that can impact work, relationships, and wellbeing. During menopause, they often become more unpredictable, intense, or even make their first unwelcome appearance. Below we look at ways to approach migraine during midlife.
Mell has personal experience of migraines and the heart-sink moment when you know one is starting is awful. It wipes out the next few hours and the following days leave you with a feeling like your brain is bruised, fatigue and brings with it added sensitivity to lights, sounds and smells.
Migraine remains one of the most underreported, underdiagnosed, and undertreated neurological conditions - despite its profound impact on quality of life. It disproportionately affects women, with around 43% of cases occurring in females. One of the key drivers behind this gender disparity is hormonal fluctuation, particularly in oestrogen levels. These shifts are thought to play a significant role in triggering migraine episodes, although the precise mechanisms are still being explored. What we do know is that oestrogen appears to influence the brain’s pain-processing pathways, offering a compelling explanation for why migraines are so much more prevalent in women than in men.
Migraine can be incredibly debilitating and is not just a headache. A severe migraine can last between 4 and 72 hours and may require bed rest. It may also be accompanied by sensitivity to light and sound that can remain for days afterwards. Many sufferers need time in a dark room with very little noise, which can be quite difficult with a family or at work.
The most common migraine is migraine without aura. Less common is migraine with aura. This type of migraine is preceded by transient and fully reversible neurological symptoms, such as zig zag or shimmering patterns, affecting your vision. These patterns are commonly called fortification spectra and can last for minutes or sometimes hours. They can occur with or without the headache phase.
Menopause & the effects of hormones
In the early stages of menopause, when periods become erratic or more frequent, migraine attacks can increase. Surgical menopause (e.g. hysterectomy and/or removal of your ovaries) can also lead to sudden hormonal changes that worsen migraines. They can also be triggered by heavy menstrual bleeding, as this increases prostaglandins, (a group of lipid compounds that have hormone-like effects on the body, responsible for the contraction-type pain we get when our period arrives). During this time of life 8-13% of women report the new onset of migraine too. Towards the end of menopause, as periods become less frequent, migraines can also lessen. (However, if you have triggers other than hormones, they may continue post-menopause).
The main reason for worsening migraine during menopause is the fluctuation of oestrogen.
Fluctuating hormone levels often coincide with other life changes - for example, children leaving home, responsibility for older relatives and job stresses. Together, these make the perimenopause a high-risk time for worsening migraine.
Hormone levels can be stabilised by using hormone replacement therapy (HRT). Migraine loves change so you should always start with the lowest dose and increase slowly as required. Migraines can potentially increase in frequency at the beginning, especially those with migraine with aura.
If you still have your uterus you need both oestrogen and progestogen HRT. A continuous HRT regimen, where both hormones are used consistently, may be better tolerated than a cyclical regimen, which involves taking oestrogen daily, but progestogens only for half of each month. This is particularly beneficial if your migraines are associated with your menstrual cycle. This would need to be discussed with your clinician.
Micronised progesterone (Utrogestan/Gepretix) can be beneficial for migraine sufferers as it acts as a neuro suppressive, so reduces neural activity that may trigger migraine attacks. The hormonal coil (Mirena) can also be a good method as it provides womb protection directly and gives a consistent level of a type of progesterone that often reduces or stops periods. (If you have had a hysterectomy, you may only need to use oestrogen-only HRT. This would depend on the reason for having the surgery).
To maintain consistent oestrogen levels in the bloodstream, it’s recommended to use transdermal oestrogen (applied through the skin). Migraine sufferers should ideally avoid most oral HRT tablets, as these carry a slightly increased risk of blood clot and stroke. However, your overall risk will be assessed when you first start HRT.
Even if you couldn’t use the combined oral contraceptive (COC) pill due to migraine with aura, you can still use HRT. This is because transdermal forms of HRT use natural oestrogen, which mimics the type produced by your body, unlike the synthetic oestrogen found in COC pills.
Your HRT dose should be sufficient to see an improvement in your symptoms, especially hot flushes. If you find migraine with aura starts or worsens for the first time with HRT it may mean that the dose is more than you need. If you change your method of HRT, for example from a patch to a gel, you may notice an increase in migraines as you may absorb the new method more effectively, so the dose may need reducing.
It’s worth noting that when a woman begins using vaginal oestrogens, a temporary rise in oestrogen levels can be detected in the bloodstream. These elevated levels typically last for a couple of weeks before settling back down. For women sensitive to hormonal shifts, this initial fluctuation may be enough to trigger a migraine episode. This should settle after the loading dose as levels drop. Don’t be put off trying vaginal oestrogens, but do be prepared for a possible initial increase in migraine. If migraines persist despite initial treatment, it may be time to explore alternative options. For vaginal dryness and discomfort, regular use of moisturisers such as YES or Sutil can offer effective relief. When it comes to intimacy, an oil-based lubricant like YES can enhance comfort and pleasure by reducing friction and protecting delicate vaginal tissues. These supportive measures can make a meaningful difference in overall wellbeing - especially during midlife transitions.
If you are taking HRT and feel it needs increasing as your symptoms are poorly controlled, make sure this is done slowly. Use each dose increase for at least 3 months before considering another change. Prepare for a possible increase in migraines at this time by discussing how to manage them with your GP. (*Be aware that migraines can also be caused by too much oestrogen as well).
Conclusion
For many women who experience hormonally driven migraines, post-menopause can bring welcome relief. As oestrogen levels stabilise, migraine frequency often declines, but this shift isn’t immediate. It can take two to three years after the final period for hormones to fully settle and symptoms to ease. That said, non-hormonal triggers, like stress, sleep disruption, dehydration or dietary factors, may still play a role. If these remain significant, migraine attacks can persist even after menopause.
Migraines during menopause aren’t just “in your head” - they’re a real, physiological response to hormonal shifts. But with the right support, they don’t have to derail your life.
If you’re navigating this phase and feeling overwhelmed, know that you’re not alone. Whether it’s through personalised HRT, lifestyle tweaks, or simply being heard, there are ways forward and we’re here for you.
Possible ways to reduce migraine incidence
Lifestyle Changes
- Regular Sleep Schedule: Aim for a consistent sleep routine. Both too much and too little sleep can trigger migraines.
- Healthy Diet: Avoid skipping meals and stay hydrated. Certain foods and drinks, like caffeine, alcohol, and processed foods, can be triggers.
- Stress Management: Practise relaxation techniques such as yoga, meditation, or deep-breathing exercises to reduce stress.
Environmental Adjustments
- Lighting: Avoid bright or flickering lights. Use a wide brimmed hat, sunglasses or anti-glare screens if necessary.
- Noise: Minimise exposure to loud noises. Consider using earplugs or noise-cancelling headphones.
- Screen Time: Take regular breaks from screens to reduce eye strain.
- Weather: Not something you can adjust but can be linked to migraine attacks.
Medical Treatments
- Medications: Over-the-counter pain relievers like ibuprofen or soluble aspirin can help (use effervescent as this absorbs quicker). Avoid using codeine. For more severe cases, prescription medications such as triptans or anti-nausea drugs might be necessary.
- HRT may stabilise your hormones however, if you aren’t eligible for HRT, your GP may consider using an antidepressant medicine such as venlafaxine or escitalopram. Clonidine – a medicine usually used for high blood pressure is also effective at reducing hot flushes.
- Mefenamic acid has also been found to be helpful as it reduces your level of prostaglandins.
- Preventive Medications: If migraines are frequent, your doctor might prescribe medications to reduce their frequency, such as beta-blockers, antidepressants, or anticonvulsants.
- Supplements: Some people find relief with supplements like magnesium, riboflavin (vitamin B2), or coenzyme Q10, but always consult with a healthcare provider before starting any new supplement.
Behavioural Strategies
- Keep a Migraine Diary: Track your migraines to identify potential triggers and patterns.
- Regular Exercise: Moderate, regular exercise can help reduce the frequency and severity of migraines.
- Hydration: Drink plenty of water throughout the day to stay hydrated.
- Therapies: Cognitive-behavioural therapy (CBT) can be effective in managing migraines.
It’s important to find what works best for you, as migraine triggers and effective treatments can vary from person to person.
Useful Websites:
https://www.nationalmigrainecentre.org.uk/
https://migrainetrust.org/get-support/resources/
Podcasts you might find helpful:
Heads Up - (run by the National Migraine Centre)
The Happy Menopause - by Jackie Lynch
Recommended Books: Managing Your Migraine by Dr Katy Munro
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