“In perimenopause, estrogen levels are falling and may be associated with worsening in frequency and intensity of migraine,” Dr Sheikh explained. This was confirmed in a study reporting that high-frequency headache was increased in perimenopausal women compared with premenopausal women.6 “This tends to level out after menopause; around two-thirds of post-menopausal women notice an improvement in their headaches,” she said.
If women with menstrual migraines, whether pure or not, are able to “predict when they are going to have their menses, and thus when they are going to get their migraines, we may offer ‘mini-prophylaxis treatments’ to try to prevent the migraines” said Dr Minen. This strategy may include treatment with nonsteroidal anti-inflammatory (NSAID) agents, estrogen supplementation, triptans, or magnesium.7 “For women with migraine who have 4 or more headache days a month, we may offer a daily preventive medication to take in addition to an abortive medication to treat the acute attack,” she added.
In weighing migraine treatment options for women in different reproductive stages, it is important to consider any other medical issues that may be present, advised Dr Sheikh. For example, when “treating pregnant women or women in their reproductive age, the risk of medications to the fetus is of the utmost importance,” she emphasized. Recent evidence suggests that several migraine therapies, including magnesium, acetaminophen, ondansetron, and butalbital may be less safe during pregnancy than previously believed and should be used with caution.4
“It is also important to note that although hormones play a role in triggering headaches, they may not always be the way to treat headaches, since hormones themselves can have adverse effects,” Dr Sheikh noted. For example, some evidence suggests that estrogen can increase stroke risk, and hormonal treatment — including combined oral contraceptives — is typically contraindicated in women who have migraine with aura.2
From puberty to menopause, women have an elevated risk of migraine. This requires vigilance on the part of the clinician in order to optimize treatment and minimize risks throughout the hormonal fluctuations that occur in women at the various stages of life.
- Peterlin, BL, Gupta S, Ward TN, MacGregor A. Sex matters: evaluating sex and gender in migraine and headache research. Headache. 2011;51(6): 839-842.
- Edlow AG, Bartz D. Hormonal contraceptive options for women with headache: a review of the evidence. Rev Obstet Gynecol. 2010;3(2):55-65.
- Sacco S, Ricci S, Degan D, Carolei A. Migraine in women: the role of hormones and their impact on vascular diseases. J Headache Pain. 2012;13(3):177-189.
- Wells RE, Turner DP, Lee M, Bishop L, Strauss L. Managing migraine during pregnancy and lactation. Curr Neurol Neurosci Rep. 2016;16(4):40.
- Begasse de Dhaem O, Seng EK, Minen MT. Characterization of sleep disturbances in headache clinic patients with migraine-like headaches (abstract PS56 of “Abstracts from the 58th Annual Scientific Meeting American Headache Society”) [published online June 6, 2016]. Headache. doi:10.1111/head.12832
- Martin VT, Pavlovic J, Fanning KM, Buse DC, Reed ML, Lipton RB. Perimenopause and menopause are associated with high frequency headache in women with migraine: results of the American Migraine Prevalence and Prevention Study. Headache. 2016;56(2):292-305.
- Tepper DE. Headache toolbox: menstrual migraine. Headache. 2014;54(2):403-408.