When I first started working at a specialist migraine clinic back in 1988, over 80 percent of people attending the clinic were women, typically women in their 40s. Most of them had had migraine since their teens or early 20s but attacks were becoming much more troublesome. Many also experienced typical perimenopause symptoms with more frequent periods, hot flushes, night sweats, anxiety and disturbed sleep.

When we surveyed women attending a specialist menopause clinic, we were therefore not surprised to find a high prevalence of migraine, affecting 42 percent of women, of whom a fifth had daily headaches. These attacks were associated with significant disability with 78 percent of women reporting very severe or substantial disability using the Headache Impact Test (HIT-6) score.

Yet most attacks were treated with inappropriate medication – one-third of women relied on paracetamol alone and one-fifth were treating migraine attacks with codeine-containing medication. Only a fifth of the women with migraine had been prescribed Triptans.

But why does migraine become more of a problem at this time of life?

Perimenopause begins in the early to mid-40s. We know that oestrogen levels mirror changes in migraine prevalence, with fluctuating levels during perimenopause increasing the likelihood of migraine and, as many women have found, menstrual migraine. These menstrual attacks are longer, are more likely to relapse, are more severe and are more disabling compared to attacks at other times of the menstrual cycle.

As menstrual cycles shorten during perimenopause, menstrual attacks occur more frequently. Hot flushes and night sweats disrupt sleep, acting as an additional migraine trigger. With time, the periods become few and far between, eventually stopping forever at menopause. But even though periods have stopped, the ovaries can still produce varying levels of oestrogen for several years more.

So, although migraine does improve with increasing time following menopause, it is not immediate. It’s important to note that improvement in migraine is only seen following natural menopause, and surgical menopause following early removal of the ovaries has been shown to worsen migraine.

What can we do to manage perimenopausal migraine?

Ensuring effective symptom treatment is obviously of paramount importance and it’s important to discuss this with your GP or healthcare provider. But if you’ve got flushes and night sweats as well as menstrual migraine, you may well be considering hormone replacement therapy (HRT).

However, our experience suggests that HRT during perimenopause can worsen migraine, which is not surprising given that oestrogen levels during perimenopause can rise to much higher levels than earlier in the reproductive years. So healthy woman with migraine without aura may benefit from hormones that suppress ovarian activity, rather than add to these already high levels.

One option is combined hormonal contraceptives which can safely be taken by most healthy women with migraine without aura until age 50. They should be taken continuously, without the usual seven day break, as these breaks can themselves trigger oestrogen withdrawal migraine. Unfortunately, combined hormonal contraception should not be used by women who have migraine aura, for whom progestogen-only methods are a safe option.

If you are considering HRT to manage menopause symptoms, either during perimenopause or post menopause, it is important to use a form that minimises hormone fluctuations as much as possible. Hence we recommend transdermal body identical oestrogen, that is oestrogen patches, gel or spray, which can provide stable hormone levels as the hormone is absorbed directly into the blood stream through the skin. Transdermal oestrogen can also safely be used by women who have migraine aura.

Unless you have had a hysterectomy you will also need to take a second hormone, progestogen. This is necessary to protect the womb lining from thickening in response to oestrogen, which could lead to cancer of the lining of the womb. For women with migraine, progestogens are best taken continuously. They are available in several different forms, each with differing effects and benefits. The Mirena intrauterine system is a great option during perimenopause as it controls bleeding and provides effective contraception by releasing very small amounts of hormone locally in the womb.

Progestogen can also be combined in a patch with oestrogen, changed twice weekly, which many women find convenient. Body identical progestogen, known as progesterone, has the advantage of being sedative when taken by mouth, benefitting sleep. However, unwanted bleeding is more common than with synthetic progestogens.

But not every woman experiencing significant flushes and sweats as well as migraine can or wants to take hormonal treatment. Given the link between serotonin and hot flushes, and the link between serotonin and migraine, it is not surprising that non-hormonal treatments for both conditions include drugs that act on serotonin such as escitalopram and venlafaxine. Although these drugs are more usually used to treat depression, they are also effective on flushes and sweats. However, they are only effective if taken in lower doses than used for depression.

Finally, don’t forget lifestyle strategies such as regular exercise, maintaining a normal body weight and talking therapies such as cognitive behavioural therapy, which have all been shown to be effective for both migraine and menopause symptoms.

You can read Dr MacGregor’s previous blog about menstrual migraine here.