|Migraine by age in women and men, in the author's "dizzy" clinic practice. This graphic clearly shows that women have far more migraine than men, and also that the peak age is not 35 as in the general population, but rather is 50 in patients who go to the clinic for help with their dizziness (in both men and women).|
While migraine generally diminishes with age, especially after the mid 50's, there is often a flare in migraine perimenopausally (MacGregor and Barnes, 1999; MacGregor 2006; Wang et al, 2003). According to MacGregor (1999), about 30% of women in menopause experience migraine headache. Menopause is defined as 12 consecutive months without menstrual bleeding. Some studies report much higher prevalence of migraine (e.g. see Loder et al, 2007).
The 30% prevalence figure is similar to the prevalence reported in 35 year old women, and thus represents a second "peak". Owada and Suzuki (2014) reported that menopause related dizziness is correlated with hot flashes. We agree.
Estrogen during perimenopause Urinary estrogen and progesterone in perimenopausal and younger women. From Martin et al, 2006. Original is from Santoro NJ, 1996.
According to Loder et al (2007), "Although one might expect that estrogen levels in premenopausal women decline smoothly and gradually during this transition, estradiol levels are in fact increased during the perimenopause, and often are higher than those of the premenstrual years. The figure above shows that estrogen is roughly 1.5 higher during ovulation than in women in mid-life. Progesterone, on the other hand, is less. Thus perimenopausal women have a steeper decline in estrogen when they menstruate than women in mid-life. In addition, in perimenopause, estradiol receptors also may be increased in tissues.
Estrogen declines markedly in the ﬁrst year after the last menstrual period and then remain low and stable. " Serum levels typically range from 10-20 pg/ml. (Martin et al, 2006).
In the author's practice, a pattern of more headaches for about 4 years following onset of menopause is common, and usually diagnosed as migraine. The duration of headaches is not studied in the literature at all as yet, but the author's experience is that there is roughly a 10% decrease in the number of patients troubled with each year, up to roughly 65., It is rare to encounter migraines in either gender after the age of 65. Medication management in the author's practice usually starts with a drug that reduces hot flashes (e.g. venlafaxine). If this doesn't work, one may (as a last resort) use drugs that suppress of hormonal fluctuation (Loder et al, 2007), see below.
Hormone treatment -- generally not used for migraine in Menopause
It should be noted here that no hormonal treatment regimen has FDA approval for migraine or headache indication. Thus all of the use of these treatments is "off label".
HRT -- hormone replacement therapy -- consists of a combination of low-dose estrogen and medroxyprogesterone. The estrogens in HRT are typically much lower strength than those in oral contraceptives. Although one would expect that HRT would help with perimenopausal migraines, the evidence for it helping is not compelling.
According to Loder (2007), "Thus, evidence suggests that all forms of HRT may have negative effects on migraine and headache complaints, but that the extent of worsening may depend on the particular regimen that is employed. " In essence, continuous regimens are less troublesome than intermittent regimens. This is puzzling - -perhaps the treatments have been too timid to stop migraine or perhaps migraines perimenopausally are triggered by something other than estrogen fluctuations. For example, perhaps the gonadatrophins modulate migraine as well.
The progesterone component is used in women who have an intact uterus to prevent uterine hyperplasia. Progesterone, per se, appears to have no effect on headaches (Loder, 2007), or perhaps a small effect (e.g. Martin et al, 2006).
HRT is generally not continued indefinitely due to the potential for long term adverse effects, including increasing the risk of breast cancer. There is an increase in risk of stroke in women with migraine and aura, and for this reason, estrogen containing drugs (including BC pills) are generally avoided. (Sheikh et al, 2018). Estrogen should be avoided in women who have a genetic predisposition to breast cancer.
Regarding the risks in menopausal women, according to a reasonably credible source, the USPSTF, HRT should not be used for "prevention of chronic conditions in postmenopausal women". By this, they mean prevention of osteoporosis (for example). The USPSTF did not consider disabling migraines, but nevertheless it does not seem prudent to use HRT unless other treatments have failed. We recommend stopping HRT for migraine after 5 years. Of course, clinical judgment must be used.
A general discussion of migraine treatment is found on other pages on this site.
Migraine prophylactic medications are often helpful for controlling the headache symptoms. We particularly favor venlafaxine in low doses for this purpose. Venlafaxine has two roles -- prevent migraine and prevent hot flashes. Migraine abortive medications such as triptans are also very useful.
Other drugs that may help manage the hot-flashes and headaches that are often combined include SSRI's (such as paroxetine and fluoxetine), SNRI's (such as venlafaxine in low doses), low-dose clonidine, and gabapentin.