Understanding the Link Between Migraine and Perimenopause

Many studies have shown that female hormones have a relationship with causing migraine headaches. Hormonal fluctuations are one of the reasons why women are nearly three times more likely to experience migraines than men. For many women, though, menopause can bring about a welcoming end to migraine headaches. Nevertheless, the time period leading up to menopause, known as perimenopause, can often make the symptoms worse before they get any better. The period of perimenopause brings with it significant fluctuations in the hormone levels, due to which people with migraine tend to experience the severity and frequency of their migraine headaches. There are many doubts and questions that exist as to why this happens. Here’s everything you need to know to understand the link between migraine and perimenopause.

The period of perimenopause is defined as the transition phase between a person’s reproductive period and the start of menopause. This is the transition period towards menopause, and it brings with it many major changes in the hormone levels in the body. While some people begin the phase of perimenopause as early as their late 30s, it usually starts in the 40s. It is essential to remember, though, that it is still possible to get pregnant during perimenopause, though the chances are less.^{(1, 2, 3, 4)}

There are many things that are still not entirely understood about the period of perimenopause and why it differs from person to person. Here’s how perimenopause is a part of the natural reproductive life cycle:

1. Menarche: The term Menarche is used to describe your first menstrual period, thus marking the start of menstruation. This usually happens between the ages of 9 to 15 years old.⁽⁵⁾ The average age for the onset of menarche is 12.4 years.
2. Reproductive Phase: These are the years that follow after the start of menstruation. They are the years during which the body undergoes regular ovulation and menstruation. In this period, a person is most likely to get pregnant.
3. Perimenopause: This is the last phase of the reproductive cycle, and it marks the transition period towards menopause when the menstruation cycle comes to an end. Perimenopause can last for two to eight years and usually begins in your 40s.
4. Menopause: The average age of menopause observed in the United States is 52 years.⁽⁶⁾ You are said to have reached the menopause stage if you complete one whole year since you had your last menstrual cycle.

According to the North American Menopause Society, people who are in the perimenopause stage may begin to notice the following signs and symptoms:⁽⁷⁾

• Hot flashes
• Irregular periods
• Mood swings
• Sleep disruptions
• Vaginal dryness

The female body goes through many hormonal changes, especially once they approach perimenopause and menopause.

For many people, the onset of puberty and the hormonal changes that take place marks the beginning of the dreaded migraine headaches. This is why it is often not surprising when the hormonal changes that happen in your 40s-50s can also have an impact on migraine.

Perimenopause is a time period marked by unpredictable hormonal changes. It is during this time that the levels of estrogen and progesterone fluctuate quite a lot. And these hormonal changes can bring about an increase in the severity and frequency of migraine attacks. This is especially true if you have had a history of experiencing menstrual migraine, which gets triggered by the changes in hormonal levels just before every menstrual period. Just before you get your periods, there is a drop in the female hormone estrogen. It is due to this decrease in estrogen levels that women experience migraine headaches just before their period. During pregnancy, the levels of estrogen increase, which gives women a break from having migraine pain. However, it is common for the migraine to start up again after the delivery of the baby.^{(8, 9, 10)}

Once the phase of perimenopause comes to an end and menopause begins, migraine episodes tend to reduce in many people. In a review of several studies, researchers discovered that nearly 50 to 60 percent of people witnessed an improvement in their migraine symptoms after reaching menopause.⁽¹¹⁾ However, for some people, migraine symptoms tend to worsen after menopause, though the exact reason for this remains unknown.

The type of menopause you have is believed to play a role in this. Research shows that natural menopause is associated with an improvement in migraine instead of surgical menopause.⁽¹¹⁾ Surgical menopause happens when some medical procedure, such as a hysterectomy, is carried out, and it causes the body to enter menopause.

Researchers believe that surgical menopause is more likely to cause a worsening of migraine symptoms because it causes a sudden fall in the hormone levels.⁽¹²⁾

Migraine is more common in people who are of childbearing age.⁽¹¹⁾ For many people who have migraines, the days before and during a menstrual period can become primary triggers for migraines. In fact, an article published in Therapeutic Advances in Neurological Disorders journal showed a 71 percent increase in the risk of developing a migraine two to three days before a menstrual period.⁽¹³⁾ During the menstrual cycle, the levels of the hormone estrogen fall right before the period begins. This sudden drop in estrogen levels may bring on a migraine without aura. An aura is a collection of symptoms that include flashing lights, sensitivity to sounds, sights, and smells, nausea and vomiting, etc., that appear right before a migraine attack in some people.

On the other hand, high levels of estrogen, which is commonly observed just before ovulation, can also trigger migraine with aura in some people.

When it comes to menopause and migraine, most population-level studies, meaning studies that look at an entire population, have found that migraine headaches do tend to improve after menopause. This is probably because a person no longer undergoes the hormonal shifts that used to trigger their migraine pain with every menstrual cycle. However, studies that looked specifically at people who were getting treated at headache centers, usually a subset of people who experience unusually severe migraine, suggested that migraine might even worsen during the period of menopause.^{(14, 15)}

This is why there is no sure-shot way to predict how menopause is going to affect a person’s migraine pattern. A change in the migraine pattern just before menopause is likely to occur due to fluctuating hormone levels.

So do these fluctuating hormones improve the migraine attacks or actually worsen them? Hormones have been linked with migraine attacks, but it is actually the changes or fluctuations in the hormone levels, instead of the amount of hormones themselves, that makes the difference. According to the American Migraine Foundation, if a fall in estrogen happens rapidly, like what can be seen just before a menstrual cycle, the chances of experiencing a migraine attack are higher. ⁽¹⁶⁾

A recent review of 19 studies done in 2021 discovered an association between migraine and estrogen withdrawal. The highest impact happens when the estrogen levels drop below 45 to 50 picograms per milliliter (pg/mL).⁽¹⁷⁾ This review also suggested that not all women experience the same effect, and more research is still needed to look at the differences between migraine and menopause in women.

Hormonal fluctuations in pregnancy also have a similar impact as estrogen levels go up during pregnancy, and most people experience fewer migraine episodes. However, after pregnancy, migraine headaches can return with a fall in estrogen levels.

And even though the estrogen levels decrease during menopause, so do the major hormonal changes. It is for this reason that migraine episodes tend to happen less frequently. While it can take several years after the start of menopause for the hormones to settle down completely, but once these hormones settle, the migraine episodes can completely stop for some people or at least reduce in severity and frequency.

So even though hormones can trigger migraine symptoms at any point during the reproductive years, the perimenopause stage is usually the time you are most affected due to migraines. This is because the hormonal changes are the most pronounced at this time, and the levels can also change in an unpredictable manner.

The good news for most people with migraine, though, is that migraine headaches usually tend to get better once they reach menopause.

It is not entirely clear as to what effect hormone replacement therapy (HRT) has on migraine. This type of therapy is usually prescribed to help people deal with the symptoms of perimenopause and menopause, especially in those who experience menopause before the age of 45. Hormone replacement therapy usually includes the use of estrogen pills or patches.^{(18, 19)}

Several studies have derived that hormone replacement therapy can actually worsen the symptoms of migraine, while some have found that the opposite is true.⁽¹¹⁾ Some evidence also shows that hormone replacement therapy patches are less likely to make the symptoms of migraine worse than the estrogen HRT pills. However, more research is still needed.

If you are interested in seeking hormone replacement therapy for treating menopausal symptoms, especially if you have migraine, you should consult your doctor and find out about the risks and benefits. If you have a migraine with aura, hormone replacement therapy may actually end up having adverse effects, including a possible worsening of the aura symptoms along with an increased risk of cardiovascular disease.^{(20, 21)}

While most headaches are usually harmless, sometimes they can be a sign of a more serious medical condition that needs to be immediate treatment. You should not waste time in consulting a doctor if your headache:

• It gets worse than any other headaches you have ever had.
• It feels different than the ones you have experienced before.
• It causes facial dropping on one side of the face.
• It is accompanied by weakness, dizziness, or confusion.
• It appears suddenly.
• It wakes you up from sleep.
• It is accompanied by fever or a rash.
• It is accompanied by an unexplained weight loss.

Hormonal changes are known to be one of the common triggers of migraine attacks. During perimenopause, a period before menopause that tends to last for anywhere between two to eight years, your migraine headaches are likely to get worse due to the fluctuating hormone levels, especially of the hormones estrogen and progesterone. For many people, the start of menopause often brings relief in the severity and frequency of migraine symptoms. This is especially true for those who suffer from menstrual migraine.

At the end of the day, it is essential to understand that migraine is an unpredictable neurological condition, and it may either get better, or it may worsen as you go through the changes that take place before menopause.

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