Experiencing a migraine headache is a common and frequently disabling condition whenever it occurs. Fluctuations in female hormones can have a profound effect on women who are susceptible to them. Additionally, they can attack during the hormonal roller-coaster that accompanies the perimenopause and early menopausal years.
Women are three times more likely to suffer from migraines than men. Why is this? The cyclical changes in hormone levels are a key trigger, explaining the worsening of migraine commonly see just before, during and after a woman’s menstrual cycle.
There are two types of hormonally-sensitive migraine sufferers:
- Those who experience their headaches during periods of lower estrogen (menses; oral contraceptive pill “off days”; the lowered hormonal levels of menopause)
- Those whose migraines worsen when estrogen levels are increased (e.g. after starting oral contraceptive pills or postmenopausal hormone supplementation).
This hormonal sensitivity may explain why migraine worsens around time of perimenopause, when estrogen levels fluctuate and decline.
Two-thirds of women’s migraines improve within a couple of years after menopause, when her body acclimatizes to lower hormone levels, although approximately 10% experience worse headaches. Approximately 25% notice no change.
Because of the migraine’s schizophrenic reaction to hormones there is no way of knowing which women will respond positively and which poorly to menopausal hormonal supplementation.
All About Migraine
So, what really causes migraines? Modern theory is that a migraine is a brain and not a vascular disorder: A disorder of “ sensory modulation” with increased sensitivity to sensory input such as pain, light, sound, smells, and head movement. Symptoms of migraines can include nausea and vomiting and are of moderate to severe intensity.
A family history of migraines suggests a genetic component. Patients who are genetically predisposed are “triggered” with changes in external or internal environments such as sleep alteration, stress, hunger, temperature changes, etc.
Estrogen and progesterone can profoundly alter levels of dopamine, serotonin, etc. in your brain, effecting the genesis of headaches and neurotransmission, all of which play a role in pain modulation.
Management and Prevention of Migraine
Treatments may be divided into two categories: Acute (getting rid of the headache once it has started) and preventative.
Acute, first line therapies, other than general lifestyle changes such as relaxation techniques, exercise, and avoiding triggers such as alcohol, may be classified into non-migraine specific and migraine specific.
You may take Aspirin, Tylenol, Advil, Aleve, or Excedrin Migraine at therapeutic doses at the first hint of a headache. If complete relief is not obtained within 30 minutes, other non-specific medications such as Fiorinal/Fioricet or the narcotic analgesics codeine, Vicodin, etc. should be taken, or the migraineur may proceed directly to migraine specific meds.
Be careful with the frequent use of non-specific remedies such as Tylenol, caffeine, codeine, and Vicodin, as using such medications regularly and frequently could actually cause some headaches.
Someone with frequent headaches (two or more per week) requires a preventative therapy, not additional acute attack treatments. Preventative therapy means that medication should be taken on a daily basis, whether or not there is a migraine; the idea is to reduce the frequency and severity of each attack. Preventative medication may be used in conjunction with acute treatments. These medications include propranolol (inderal), tricyclic antidepressants (e.g. Elavil, etc.), valproic acid (Depakene), gabapentin (Neurontin) and others. Estrogen as well can be considered under the heading of preventative therapy in women.
Hormonal supplementation does not increase the risk of stroke in patients with migraine. If a woman complains of classical menopausal symptoms as well as worsening migraine, it’s reasonable to start Hormone Replacement Therapy (HRT). A transdermal preparation (patch or cream) may be less likely to exacerbate headaches than oral, especially if the oral is conjugated estrogens (Premarin).
If hormonal supplementation significantly improves menopausal symptoms but causes worsening headaches, a step-wise reduction in dosage (instead of stopping the HRT) may resolve the situation. If this fails, the estrogen type should be changed. There is evidence that converting from conjugated estrogens to pure estradiol, from a synthetic to a bioidentical (especially transdermally) may help.
If alterations in the estrogenic components of HRT are unsuccessful in improving headaches, similar alterations may be made in the progestagenic component, lowering dosage, switching from a synthetic (e.g. Provera) to the bioidantical progesterone. You can discuss this with your doctor.
The bottom line: Every woman is an individual, including a woman with migraine.
You shouldn’t have to suffer.
Have your health care practitioner work out a regimen to fit you.
(Reference: ìMigraine, Menopause and Beyondî by Miles J Levy, M.D., and Peter Goadsby, M.D. In Menopause Management (May/June 2003).