Menopause headaches: why migraine changes and what helps

Menopause headaches are common. Many women find that their migraine attacks increase in the years around the menopause, just when they hoped things would improve. The cause is changing hormone levels, oestrogen in particular, and the good news is that a lot can be done about it.

What is the menopause?

The menopause is when your periods stop because of lower hormone levels. In the UK it usually happens between the ages of 45 and 55. The perimenopause is the time before this, when hormone levels change and symptoms such as hot flushes, poor sleep and mood changes often start. It can last several years. The NHS website has general information on the menopause and its symptoms.

Why do headaches get worse during the menopause?

Headaches around the menopause are almost always a form of hormonal migraine. Migraine is an inherited brain condition in which the brain reacts strongly to change, and hormonal changes are among the most powerful triggers.

During the perimenopause, oestrogen levels rise and fall more and more irregularly. It is not low oestrogen as such that triggers migraine, but the drop in oestrogen. The larger and less predictable the swings, the more attacks you may have.

This works in a similar way to menstrual migraine, where the fall in oestrogen just before a period triggers an attack. During the perimenopause these swings become more erratic and harder to predict, which makes menopause headaches especially difficult.

Which phase of the menopause is worst for migraine?

• Perimenopause (the years before your last period): usually the hardest phase for migraine. Hormone levels change strongly and unpredictably, and many women have more frequent and more severe attacks than ever before.
• Menopause (when you have not had a period for 12 months): a turning point. From here, hormone levels gradually settle.
• Postmenopause: for many women, attacks become less frequent as hormone levels are more stable. This is not true for everyone, and some women continue to have migraine after the menopause.

There is still little research on migraine in women over 50, so it is not always possible to predict how your headaches will develop after the menopause.

What are the symptoms of perimenopause migraine?

Migraine during the menopause has the same symptoms as other forms of migraine, but attacks can be more intense or more frequent. Not everyone has every symptom:

• throbbing or pounding headache, often on one side
• nausea
• sensitivity to light and sound
• tiredness and difficulty concentrating
• mood changes (which are also part of the menopause itself)
• aura (visual disturbances, tingling) in some women

Menopause symptoms such as poor sleep, hot flushes and mood changes can also trigger migraine attacks themselves, which can create a vicious circle.

How are menopause headaches treated?

Treatment of menopause migraine is not fundamentally different from treatment of other migraine. What is different is that it has to take the hormonal context into account.

Acute treatment

Triptans work for most women during the menopause too, and work best when taken early in an attack. Some people also use over-the-counter painkillers, which we do not prescribe; your GP or pharmacist can advise on them. Whatever you use, avoid taking acute medication too often: using painkillers on 15 or more days a month, or triptans on 10 or more days a month, can cause medication overuse headache.

Preventive treatment

If you have frequent attacks, for example on four or more days a month, preventive treatment is an option. Our migraine specialists can offer the monoclonal CGRP inhibitors erenumab, fremanezumab and galcanezumab, and the gepants atogepant and rimegepant. These medicines were developed specifically for migraine. Other preventive options exist, and your GP can discuss them with you.

Hormone replacement therapy (HRT)

Some women consider HRT to ease menopause symptoms. The link between HRT and migraine is complex: in some women migraine improves, in others it gets worse. Steady doses of oestrogen through the skin (patches, gel or spray) are often preferred for women with migraine. We do not prescribe HRT. It is always an individual decision to make with your GP or a menopause specialist.

What can you do yourself?

• Keep a headache diary. It helps you and your migraine specialist spot patterns.
• Look after your sleep. Poor sleep is a common trigger, especially during the menopause.
• Stay active if you can. Some people find that regular, moderate exercise reduces how often attacks happen.
• Review your medication. The best treatment can change during the menopause, so discuss it with your migraine specialist.

Remember: migraine is not your fault. It is an inherited brain condition. The menopause can make it harder for a while, but good treatments are available.

When should you see a specialist about menopause headaches?

If your migraine gets worse or more frequent during the menopause, or your current medication no longer works well, it is worth seeing a migraine specialist. At The Migraine Clinic you get a personal treatment plan that takes the hormonal context of the menopause into account. All our consultations are by video, so where you live does not matter, and you do not need a referral.

Frequently asked questions about menopause headaches

Do menopause headaches go away on their own?

For many women, attacks become less frequent after the menopause as hormone levels settle. This is not true for everyone: some women continue to have migraine afterwards.

Can HRT help menopause migraine?

HRT improves migraine in some women and makes it worse in others. It is an individual decision to discuss with your GP or a menopause specialist.

Why do my headaches get worse during the menopause?

During the perimenopause, oestrogen levels change strongly and unpredictably. It is the fall in oestrogen that triggers migraine attacks, and the more erratic the changes, the more attacks you may have.

Which medicines help with menopause migraine?

The same medicines as for other forms of migraine: triptans for attacks, and preventive options such as the monoclonal CGRP inhibitors erenumab, fremanezumab and galcanezumab, or the gepants atogepant and rimegepant. Your migraine specialist will look at which approach suits you best.

Is every headache during the menopause migraine?

No. Tension-type headache is also common at this time. A proper diagnosis from a specialist helps you get the right treatment.

Next steps

Not sure whether your headaches are migraine? Take our migraine test, read about preventive medication, or see how to start.

This article was written by the medical team of The Migraine Clinic.