Menopause and midlife
We look at the key issues for women who experience migraine during the onset of their menopause
At least 90% of people with migraine start having attacks before the age of 40. Most people have their first attack during their teens or early twenties. It is rare for migraine to start later in life. Typically, migraine becomes less severe and frequent, and may even disappear, by around the age of 50. For some women this is associated with their menopause, for others it may be retirement or reduced stress.
The impact of the menstrual cycle
Around 50% of women with migraine say their menstrual cycle directly affects this. The whole menstrual cycle, not just your period, is associated with biological changes in your body, both physical and psychological. Sex hormones, oestrogen and progesterone, and the physical and chemical processes that go towards producing them, all have a widespread effect on your body.
It has long been recognised that there is a close relationship between female sex hormones and migraine, and that some women are more sensitive to the fluctuations within the menstrual cycle such as the time just before your period when, studies suggest, migraine attacks can be the result of falling oestrogen levels in the later phase of the menstrual cycle. Factors such as prostaglandin (a naturally occurring fatty acid that acts in a similar way to a hormone) release may also be implicated at this time.
The onset of the menopause
From about the age of 40 onwards, you become less fertile as your ovaries gradually stop producing eggs each month. The time from when your periods become irregular until they stop is called the peri-menopause. The menopause marks the time when your periods stop completely. This process can last as long as twenty years. The average age for the menopause is between 51 and 52 years with a range of 40 to 60 years.
You may find that your migraine attacks are linked to your periods during the peri-menopause. The ovaries produce less oestrogen and changes in your hormone levels can make your migraine attacks become more severe or happen more often.
In the few studies that have been conducted it is suggested that the menopause makes migraine worse for up to 45% of women, 30-45% do not notice a difference and 15% notice an improvement. Some women find their attacks continue to follow a cyclical pattern years after the menopause and the reason for this is unclear.
It is recognised that the hormonal cycle can continue for some years after the last menstrual period, although the hormone changes are not sufficient to result in menstruation but could still provoke migraine. In these cases, hormones as a trigger factor for migraine should settle within 2 to 5 years after the menopause.
However, cyclical migraine can occur for reasons other than the menstrual cycle – our bodies run on a whole system of different hormonal “clocks”, which could also play a role in migraine.
Other non-hormonal triggers may become more obvious after your menopause, as well as additional ones that develop such as neck tension.
These may provoke attacks in a cyclical pattern. This works on the pattern of an individual having a “threshold” to migraine and different factors building up over time to cross the threshold and trigger migraine.
The menopause can be a difficult time for women with migraine. The irregularity of your periods can make it harder to cope with your migraine as they may be more difficult to predict. Typically the problems that can be experienced at the menopause (hot flushes and night sweats) result in disturbed sleep, adding to your stress levels and therefore increasing the likelihood of you experiencing a migraine.
Keeping a diary
Keeping a diary for three months is a helpful way to see if there is any link between your migraine, your periods and your menopausal symptoms. After three months you can review your diary and see if your migraine can be managed better. It is helpful to take your diary to show your GP so that you can discuss the best course of action to manage your migraine and your menopause.
Hormone replacement therapy (HRT)
HRT is given to women to treat symptoms of the menopause such as hot flushes and night sweats.
There is little research evidence to be found on the effects of HRT on migraine in women. It can help some women but may aggravate it for others. HRT is not suitable or necessary for every woman, nor is it a problem free treatment. If you decided to try HRT it is important to try it for three months to give your body the time to find its balance. Being a woman with migraine is not in itself a reason to avoid HRT although other health issues may need to be considered such as the incidence of breast cancer in your family.
HRT if taken in a way that suits you with the right dose can often help peri-menopausal migraine.
If you need HRT for menopausal symptoms but develop headaches as a result of the treatment managing your headaches can be difficult. It is not, however, impossible. You will need to work with your medical practitioner to find the right dose and the right hormone balance. Also, by trying different methods of taking HRT you can help to find the best course of treatment for you.
There are many different types of HRT available and the effect on migraine can vary depending on the type used. So, for example, you may find that switching from pills to patches improves your headaches. Non-oral forms of HRT provide the most stable levels of hormone and are usually better for women with migraine. These can be in the form of a skin patch or gel which you rub on your skin.
If one type does not suit you, it is well worth trying another. HRT containing the lowest dose of oestrogen that will effectively control your menopausal symptoms and produce the most stable levels of oestrogen should be used if your migraine becomes worse following HRT.
What are the risks of HRT for women with migraine?
There is no research based evidence to suggest that women who have migraine and are using HRT have an increased risk of having a stroke (ischemic CVA).
Most doctors recommend that you start HRT around the time of the menopause and take it only for a few years. It can have the benefit of reducing the risk of osteoporosis and bone fractures.
- Clonidine (dixarit) is a drug sometimes prescribed for the management of high blood pressure (hypertension). It is licensed for menopausal hot flushes and migraine prophylaxis (prevention). However, it is not commonly used for migraine prevention because of its limited effectiveness. It can sometimes be helpful if you are experiencing menopausal hot flushes and migraine and cannot or do not wish to take HRT. You should not take Clonidine if you have a history of serious depression as this can be made worse.
Non drug treatments
If you are experiencing menopausal symptoms which are distressing it is worth remembering that these and your migraine can be helped by regular gentle exercise and a healthy diet. This can also help protect you against other diseases such as heart disease and osteoporosis.
- Herbal medicines
Whilst, there is still little scientific evidence supporting the efficacy of complementary medicine, there are a wide variety of complementary and alternative treatments available to help relieve menopausal symptoms.
It is important to remember that both conventional and herbal medicines can have side effects and may interact with other herbs and conventional medicines. You should therefore tell your doctor if are using a herbal medicine and equally, you should tell your herbalist if you are taking any prescribed or over the counter medication so they can advise you on any possible problems.
The most common complementary treatments for the menopause are:
- Agnus castus also known as Monks Pepper or Chasteberry extract is available as a tincture or in tablet form. It may help the peri- menopausal phase to settle hormone fluctuations.
- Isoflavones are plant oestrogens, often called phytoestrogens and can be helpful for flushes and sweats. Two common sources are soy and red clover. Studies using isoflavone supplements of 40 to 80 mg a day are recommended but it can take several weeks before any benefit is seen. Side effects are few.
- Evening primrose oil is thought to be useful for breast pain, mood swings and in some women, for hot flushes. Again it can have side effects including headache, skin rashes and nausea.
Menopause brought on by surgery does not usually improve migraine and it may even make it worse, especially if the ovaries are removed as well as the womb (hysterectomy). If a hysterectomy is required for other medical reasons, the effects may sometimes be reduced by oestrogen replacement therapy.
You should let your doctor know if you start to get migraine later in life or if you experience any change in the typical pattern of migraine symptoms or develop new symptoms. It may be that your doctor would like to give you a check-up and perhaps modify the management of your migraine.
Try and keep drug treatments to a minimum as your body may not tolerate drugs as well as you get older, especially if you are taking drugs for other medical conditions. In addition, any other co-existing medical condition can become another trigger for migraine.
Although a few women continue to have regular attacks after their menopause, for most women the end of a natural menopause can be a time of significant improvement in migraine.
Women’s Health Concern, 4-6 Eton Place, Marlow, SL7 2QA. Website: www.womens-health-concern.org