Let’s Talk Menopause spoke with Cleveland Clinic’s Dr. Pelin Batur, MD, about hormonal migraine.
Migraine can range from a nagging ache to an utterly disruptive pain—the spectrum is wide. Headaches that people often attribute to sinus or tension are often migraines. More than 90% of chronic headaches that come to a doctor’s office are actually migraines. Because migraine takes many forms, it is often under-diagnosed.
There are many causes of migraine—not all are due to hormone levels. Changes in hormone levels, though, can be a source of migraine. In general, for women who have a history of hormonally mediated migraines, they tend to be worse around the time of estrogen drops such as right before getting one’s period and also around the time of ovulation.
Hormonally induced migraines, though, are among the worst possible ones—they’re more likely to disrupt a person’s ability to function and may cause nausea and vomiting and, unfortunately, they’re less likely to respond to treatment.
These hormonally linked migraines are worse for premenopausal women who experience surgical menopause. This is due to the abrupt change—the precipitous decline—in hormone levels. The same is true for postpartum women experiencing more migraine.
Perimenopause is a roller-coaster of hormonal fluctuations which is why many women experience new or worsening hormonal migraines. If you are perimenopausal and experience such migraines, you need a treatment plan that regulates your hormone levels. We all know the fundamental over-the-counter treatment options for headaches, but the focus in treating hormonally triggered migraine needs to be on managing the ovulatory up-and-down swings. The goal is to keep hormone levels within a more balanced range to prevent the migraines from occurring in the first place.
Doctors can do this by prescribing hormonal contraceptives. The hormone levels in birth control pills best meet the existing levels in perimenopausal women, whereas menopausal hormone therapy tends to have lower doses, and often cannot control the fluctuations of hormones.
Once one becomes postmenopausal, they can consider hormone therapy because after reaching menopause, while hormone levels do fall, they stabilize. The good news is that women whose headaches are hormonal in nature typically get a reprieve from migraines after reaching menopause.
It’s important to note that the majority of the birth control pills that people could be prescribed may make headaches worse. One doesn’t want to be on medicine that continues to make the hormones fluctuate. The regimens that work well are the ones that have the same hormone dose every day and avoid the placebo time that causes the withdrawal bleed. The goal is to keep hormones as steady as possible. The birth control must be monophasic, meaning that each pill provides the same level of hormone throughout the entire pack: the same dose of estrogen, same dose of progestin. Skip the placebo pills to get the same dosing every day.*
An important thing to note about birth control treatment is that if you have migraines that present with aura, the guidelines for birth control differ as the risk of stroke is a bit higher. Lifestyle changes—diet, exercise, sleep hygiene, stress management—do make a difference as well. Supplements such as magnesium, B-vitamins, and Feverfew may also help.
Many women have experienced migraines for years. If one is experiencing new headaches, she should consult with her primary care doctor. Hormonal changes are not the only cause of migraines so an evaluation is necessary. After this, if migraines persist, one can consult with a headache specialist.
Not all ob-gyns are trained in medical issues related to the menopause transition, so I would encourage women to visit the North American Menopause Society to find a menopause trained provider near you.
*For more detailed information about birth control and migraine, please read Dr. Anne Calhoun and Dr. Pelin Batur’s article: Combined hormonal contraceptives and migraine: An update of the evidence.
Pelin Batur MD has been at the Cleveland Clinic since 1998; she works in the Department of Subspecialty Care for Women's Health, within the Ob/Gyn & Women's Health Institute. She is a Professor of Ob/Gyn & Reproductive Biology at Cleveland Clinic Lerner College of Medicine of Case Western Reserve University.