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We're often asked about the impact of the menopause transition and the associated fluctuation in oesterogen levels on women who suffer from migraine. In this information leaflet, our experts explain what migraine is, its causes and different types, how female hormones impact migraine, and if, as a migraine sufferer, you can take HRT.
A person with migraine will feel well most of the time but can experience episodes of ‘migraine attacks’. A migraine attack is a set of symptoms that last between 4-72 hours and then fully resolve. While different people get different symptoms during a migraine attack, some common symptoms include:
When a migraine attack happens, a person is usually not able to continue with their normal activities and they may want to be alone in a dark and quiet environment until it has resolved. Being still, with minimal stimulation, can help to manage migraine symptoms when they are happening. Migraine is recognised by the World Health Organisation as the third most disabling condition in the world and an individual attack is considered a disabling experience.
There are four phases to a migraine attack. However, not everyone will experience all four and, if you have migraine, you may even notice that your phases differ between your attacks:
The three most common types of migraine are:
There are also other rarer types of migraine that present with their own distinct pattern of symptoms.
Migraines can run in families meaning you may have a predisposition to them. Up to 80% of people who have migraine have a close relative with the condition. There are however triggers that increase the chance of getting a migraine in some people. Examples of triggers include:
During your menstrual cycle, your levels of oestrogen fluctuate and this can sometimes act as a trigger for a migraine attack:
In the lead-up to the menopause (known as the perimenopause), oestrogen levels fluctuate erratically, taking you on what can feel like a hormonal rollercoaster ride. Because of this, migraine attacks can become more frequent, severe and unpredictable. Sometimes this can be the first time a person experiences a migraine. Symptoms associated with the perimenopause such as hot flushes, night sweats, poor sleep, anxiety and fatigue can also trigger a migraine.
It is important to remember that although the perimenopause marks a time when your migraine frequency can increase or start for the first time, this does not happen to everyone. Furthermore, after the menopause, your fluctuations in oestrogen will lessen and migraine attacks usually settle after a few years. This can feel quite welcoming to those who have struggled with hormone-related migraine.
The answer to this is yes and for some women, some types of HRT can actually improve migraines by reducing hormonal fluctuations and improving menopausal symptoms.
Women are often worried about taking HRT when they suffer migraine because they have been advised in the past that they shouldn’t take the combined hormone contraceptive pill. This is because there is an increase in the risk of blood clots and stroke as a result of taking the oral contraceptive pill. For most women, this risk will be very small. If you suffer from migraine with aura, the baseline risk of stroke may be slightly higher than for someone who does not suffer from migraine. The risk of having a stroke is still very low and you are more likely to suffer a stroke as a result of other risk factors, such as smoking or high blood pressure.
Adding the combined pill with oral synthetic oestrogen then further increases the stroke risk which is why migraine sufferers with aura are advised not to take it. If HRT is taken with oestrogen in tablet form there is a small increase in the risk of blood clots and stroke also, so taking HRT containing oral oestrogens is not advised for migraine sufferers. Adding oestrogen through the skin will not affect this risk and so is the safest option if you suffer from migraine.
It is important to select your HRT carefully and use a regime that minimises hormone fluctuations as much as possible. Below are some top tips to help you:
Your oestrogen replacement:
Your progestogen replacement (this is required if you still have a womb, if you have womb lining left after surgery, or sometimes due to the presence of endometriosis):
The clinical data on this is limited and testosterone is not indicated to treat migraine.
There is no evidence that vaginal oestrogen can trigger migraine when used long-term. Very occasionally when a vaginal oestrogen is first started there can be a temporary increase in migraine but this should settle quickly after a few weeks.
Migraine may need separate management in addition to HRT. Some medications can be taken to treat migraine attacks when they occur. These include simple painkillers such as paracetamol and aspirin. Other medications that can also help include triptans and anti-sickness medication.
If your migraines are very frequent you might benefit from taking a daily preventative medication – as well as, or instead of, HRT. Examples include beta blockers (for example propranolol), amitriptyline, topiramate and candesartan and these can be discussed with your GP. You may need a referral to a neurologist to discuss any next steps.
There are things that you can do to help reduce the frequency of migraine attacks. These include:
Dr Abbie Laing
Dr Clare Spencer
Registered menopause specialist, GP and co-founder
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Moehlig RC. Methyl testosterone for migraine of women; report of sixty cases. J Mich State Med Soc 1955; 54: 577–579. PubMed.
MacGregor A. Migraine, menopause and hormone replacement therapy. Post Reproductive Health. Vol 24;1 2018
MacGregor A. Migraine and HRT. Tools for clinicians.