Guest blog by Lisa Horwitz, Community Support Ambassador with the Migraine World Summit
Approximately 60% of all women who experience migraine report a connection between their menstruation (periods) and their migraine attacks, according to Cleveland Clinic. Interested in better understanding this connection, Christine Lay, MD, FAHS, professor of neurology and Deborah Ivy Christiani Brill Chair in neurology research at the University of Toronto, and director of the headache program at Women’s College Hospital, has been actively involved in research and teaching about migraine across the lifespan, especially as it applies to menstrual health and the transition to menopause. During an interview for the 2024 Migraine World Summit, Dr. Christine Lay shared what she has discovered through her practice.
How does migraine change for women as they move through perimenopause and menopause?
Perimenopause is the period of time before a woman enters menopause, which is marked by not having a menstrual period for 12 consecutive months. Perimenopause typically begins around age 40 and can last up to 10 years. During perimenopause, hormone levels start to decrease as the body transitions out of its reproductive years. These hormonal changes can cause symptoms, such as hot flashes, difficulty sleeping, brain fog, and mood changes.
Migraine attacks can become more frequent, intense, and harder to treat during perimenopause. Dr. Lay says that an increase in migraine attacks may even occur a few years prior to the start of perimenopause. In fact, she says, “It may be one of the first signs that perimenopause is on its way.”
Dr. Lay elaborates that during perimenopause, “women begin to notice they have more frequent attacks, they’re more burdensome, they’re harder to get rid of, [and] they have to be more aggressive with their acute therapy.” In addition, “many women will move from what perhaps was low frequency or even higher frequency, episodic migraine and now they’re stuck in chronic migraine.”
It is commonly believed that the increase in migraine attacks is caused by changing or decreasing levels of estrogen and progesterone. Even though hormones play a role in these migraine attacks, Dr. Lay believes that it is more important to “look at the clinical picture” of migraine. This includes tracking how a patient is feeling throughout their menstrual cycle, the number and length of attacks, and a patient’s overall quality of life. Relying on hormone testing alone captures too short of a period of time to provide any useful information for the treatment of migraine.
How do women treat migraine during perimenopause and menopause?
Dr. Lay emphasizes that lifestyle factors are very important to migraine treatment. To treat migraine during both perimenopause and menopause, she recommends:
- Treating attacks early with acute medicines (e.g., non-steroidal anti-inflammatory drugs, triptans, gepants, neuromodulation devices)
- Treat again if you still have symptoms 2 hours after first treatment
- Maintaining a healthy lifestyle that helps manage migraine, which includes:
- Consistent sleep schedule
- Body movement and exercise
- Adequate hydration and consumption of regular meals
- Reduction and management of stress
- Use of daily preventive medicines to reduce attack frequency
Dr. Lay places particular emphasis on the importance of high quality sleep in the treatment of menopause:
“I always say one of the most important lifestyle factors is sleep. What time are you going to bed? How long does it take you to fall asleep? What are you doing before you fall asleep? Talk to your doctor about your sleep if you don’t feel like you’re getting a good night’s sleep and waking refreshed.”
Does reaching menopause mean the end of migraine attacks?
Hormones can continue to fluctuate for several years after the menopause transition, which may continue to contribute to increased attacks. After the hormonal fluctuations end, some women do experience a reduction in attack days.
However, migraine is a progressive disease, and menopause will not put an end to all attacks. Dr. Lay explains that an improvement in migraine depends on “how [individuals] entered perimenopause or the early menopausal years. Were they having a hard time? Did they have chronic migraine? Were they stuck perhaps in medication-induced headaches?” From her experience, Dr. Lay believes these factors may cause migraine attacks to become more disabling, more frequent, harder to get rid of, and longer in duration.
“If that woman hasn’t been offered or didn’t take proper medications, wasn’t following lifestyle recommendations … she’s not going to find this sort of sudden benefit of menopause because she entered menopause in a tough place,” Dr. Lay says. Menopause is not a fix-all for migraine.
Do patients have to give up triptans when they reach menopause?
Triptans are a family of tryptamine-based drugs commonly used to treat migraine and cluster headache by quieting down overactive pain nerves in the brain.
“Once upon a time, we would’ve thought about things like triptans being dangerous, [but] there’s been a lot of information that has come forward showing the absolutely outstanding safety profile of these medications, and so we don’t worry so much about age being a cutoff for these medications.” This may be welcome news to patients worried about having to give up an effective acute medicine as they age.
As always, people should continue to work closely with their physician, who has the full picture of their health, when considering a migraine treatment plan. Migraine treatments are tailored specifically for each patient; what is safe for one patient may carry health risks in another. Additionally, treatments that worked for women in their 20s may be less effective as they transition to menopause. Women should work with their health care team to explore treatment options across the lifespan.
Moving forward in action
Navigating perimenopause and menopause can be challenging on its own—and even more so with the added complexity of migraine. Working with a health care provider who understands the intricate relationship between perimenopause and migraine can greatly impact management strategies and overall well-being.
Watch the full interview with Dr. Lay during the 2024 Migraine World Summit to learn how to proactively manage your health and thrive during this transition.