Perimenopausal and menopausal migraine in clinical practice

Migraine often worsens before and during menopause. Why does this happen and what is the effect of hormone replacement therapy or hysterectomy? Professor Christine Lay, University of Toronto, Canada, shared her expertise and answered these questions at the Virtual Scottsdale Headache Symposium 2020.

Clinical manifestations

Hormone changes and menopausal symptoms can worsen migraine

The prevalence of menopausal migraine ranges from 10% to 29%,1 and it can worsen in severity and frequency in response to hormonal fluctuations.2,3 Hormonal changes, especially a fall in estrogen, are common triggers,4 said Professor Lay.

Women with menstrual migraine are most at risk3 and the hormonal influence is primarily associated with migraine without aura rather than migraine with aura.5

Menopausal-associated vasomotor symptoms, poor sleep, and mood change can compound morbidity, added Professor Lay.

 

Management

The menopausal transition is a difficult time for women with migraine and aggressive treatment is needed, said Professor Lay.

Anti-migraine medications can be very effective, but an individualized strategy is required for each patient—and this may include acute and preventive non-hormonal and hormonal therapies as well as behavioral approaches.5

 

Migraine and hormone therapy

Hysterectomy is associated with worsening migraine

Women with migraine may ask if they can have hormone replacement therapy (HRT) for their menopausal symptoms, said Professor Lay. HRT safety will depend on the patient’s other risk factors such as smoking, hypertension, and obesity, but a short course of HRT is usually safe, although migraine could worsen.

HRT is generally limited to patients who have migraine without aura.5 It is generally not advised patients who have migraine with aura due to an increased risk of stroke.6

Women with migraine may also ask whether they should have a hysterectomy. The answer is no, said Professor Lay, because hysterectomy is associated with a higher risk of worsening migraine.7

 

Prognosis

Postmenopausal HRT can worsen migraine

Although migraine may improve after the menopause, a study of 103 postmenopausal revealed that 15% continue to have migraine,8 said Professor Lay. Migraine in the post-menopausal period is associated with higher levels of mood disorders, disability and more menopausal symptoms.8

She noted that migraine improvement is more likely after spontaneous rather than after surgical menopause,1 and that postmenopausal HRT has been associated with worsening migraine in observational population-based studies.1

 

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Our correspondent’s highlights from the symposium are meant as a fair representation of the scientific content presented. The views and opinions expressed on this page do not necessarily reflect those of Lundbeck.

References
  1. Ripa P, et al. Int J Womens Health 2015;7:773–82.
  2. Pavlovic JM, et al. Neurology 2016;87:49–56.
  3. MacGregor EA. Maturitas 2020;142:24–30.
  4. Allais G, et al. Neurol Sci 2018;39(Suppl 1):11–20.
  5. Pavlovic JM. Women's Midlife Health 2020;6:11.
  6. Sheikh HU, et al. Headache 2018;58:5–21.
  7. MacGregor EA. Curr Treat Options Neurol 2009;11:10–17.
  8. Carturan P, et al. Arq Neuropsiquiatr 2016;74:999–1002.
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