a woman holding her head while eyes closed

Migraine and Hormones

Migraine is a common and distressing condition affecting 15% of the population (up to 25% of women) and is estimated to cause 100,000 people to miss school or work every day. Migraine is a disorder of the brain where the nerves become over-stimulated and cause a cascade of chemicals to be released. The symptoms vary, most adults with migraine will experience headache, described as a throbbing pain, which can be accompanied by nausea or vomiting, along with an increased sensitivity to light, noise, movement, or smell. What is the link between migraine and hormones?

Migraine attacks

These can be divided into different types, the most common ones are:

  • Migraine with aura (20%) – when there are temporary disturbances for up to an hour before the head pain starts, like seeing flashing lights, zig zag lines, blurred spots. Rarely some people experience dizziness, numbness, have ringing in the ears, slurred speech or confusion. Aura symptoms are fully reversible, develop over 5 minutes and last 5-60 mins.
  • Migraine without aura (80%) – this is the more common type of migraine where the pulsating, throbbing or banging head pain comes on without any aura or warning signs. The pain often occurs alongside sensitivity to light and nausea.
  • Aura without any headache – this type has some aura like symptoms, but the head pain does not develop

You may have some symptoms a few days before the migraine attack such as fatigue, yawning a lot, changes in mood, peeing more, difficulty concentrating or a stiff neck, and you may also have symptoms for a few days after the attack called postdrome symptoms.

National migraine centre: migraine warning signs

Migraine can be episodic, where you have infrequent migraine attacks, less than 15 days a month, or chronic, where you have more than 15 headache days each month, for 3 months or more.

How to know if you have migraine?

Do you have episodic unilateral or bilateral headache lasting 4-72 hours? If you answer yes to two of the following then migraine headache is likely:

  • Does the light bother you when you have a headache?
  • Do you have headaches that impair your ability to function?
  • Do you feel nauseus or sick to your stomach when you have headache?
How to know if you have aura?

Do you have visual disturbances that? If you have answered yes to all three questions is ‘yes’ a diagnosis of migraine aura is likely.

  • Start before the headache?
  • Last up to one hour?
  • Resolve before the headache?

These symptoms are atypical and need to be discussed with a Dr please:

  • Motor symptoms like muscle weakness, double vision, visual symptoms affecting only one eye, poor balance or reduced consciousness
  • Migraine lasting more than 72 hours.
  • Aura symptoms which last more than an hour.
Why might migraine become worse in perimenopause?

When menopause happens, the ovaries stop ovulating and producing eggs, and oestrogen levels remain low. Menopause is said to happen one year after your last natural menstrual period. Perimenopause is the time running up to this, when hormone levels can fluctuate wildly, your menstrual cycle may be changing and you may be experiencing symptoms of menopause, and this time can last up to 10 years before the periods stop. Perimenopausal migraine, where migraine symptoms worsen in the years leading up to the menopause, is often characterised by migraine attacks which occur more frequently and sometimes also last longer. The main reason for worsening migraine during perimenopause is the fluctuation of oestrogen. Post menopause, hormone levels are low and remain stable so if hormones are triggering your migraine, once the hormone levels settle, you may find that your migraine attacks improve, but this could take two or three years to settle.

Although there is no simple cure for migraine, but there are things that will help manage and control migraine and can often greatly reduce how severe they are and how often the migraine attacks occur. Lets start with migraine triggers.

Migraine triggers

A migraine trigger is anything that can result in migraine. Triggers might be easy to control, like avoiding dehydration, harder to control, like avoiding stress, or impossible to control, like changes in the UK weather.

Some common triggers for migraine are:

  • changes in routine, travelling and changes to sleeping patterns, work and weekend change of behaviour
  • hormones – either during the menstrual cycle or during perimenopause where hormones can fluctuate
  • stress -anxiety and emotion play an important role in headache and migraine.
  • too much or too little sleep, sleeping in at a weekend can sometimes trigger an attack
  • caffeine and alcohol
  • environment (temperature changes, humidity, glaring lights, loud noises)
  • smells from perfume, smoke, paint, bleach etc.
  • computer work is often a cause of headache
  • delayed or missed meals often result in a drop in blood sugar, which can trigger migraine.
  • dehydration – aim to drink about 8 glasses of water a day and avoid fizzy drinks if aspartane affects your migraine
  • exercise – build up slowly when you start

Migraine, perimenopause, menopause and Hormone Replacement Therapy (HRT):
  • If you have migraine with aura, you cannot take the combined contraceptive pill.
  • If you have migraine but have no history of migraine aura, you may benefit from using the continuous combined hormonal contraceptive pill until you are 50 years old, if it is safe for you to take this. You can discuss this with your Dr, some women choose this to help with their menopause symptoms and to act as contraception.
  • It is possible to take HRT in perimenopause and menopause, if you have migraine with aura. For most women who experience migraine in perimenopause and menopause, taking the right type and dose of HRT can improve the severity and frequency of migraine attacks.
  • Which oestrogen in HRT is safest? Transdermal bio-identical /body identical oestrogen as a gel, patch or spray, at the lowest dose to control the hot flushes and night sweats.
  • If you need to take progestogen as part of your HRT, which ones can you talk with your Dr about? It may be best to consider continuous combined HRT if you need progestogen, taking it daily rather than cyclically, to give stability. The 52mg levonorgestrel intrauterine system (commonly known as a Mirena), taking transdermal norethisterone (in combined HRT patches) or using bio identical / body identical micronised progesterone like Utrogestan or Gepretix. You can discuss this option with your Dr to see if taking HRT like this is right for you.
What about non hormonal options to help relieve of vasomotor symptoms (hot flushes and night sweats or chills) and help to prevent migraine?

Medications used include Escitalopram and Venlafaxine.

What can help with menstrual migraine?

Menstrual migraine refers to migraine attacks that are linked to menstruation, and that occur with your period. You may have migraine attacks at other times in the month. There is a link between migraine and falling levels of the hormone oestrogen. The natural drop in oestrogen levels before your period starts is linked to menstrual migraine. Women who have heavy and painful periods have higher levels of prostaglandin (a different hormone), which may also play a role in a menstrual migraine.

There are different options available to discuss with your doctor. It could include non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, naproxen or mefenamic acid might help during the acute attack. Some women who can take a hormonal contraceptive pill may find this helpful, or HRT can be used to stabilise the hormonal fluctuations. Triptans can be also used, as below, these may be effective or may delay the migraine attack. Discuss what might be right for you, with your doctor.

Short-term preventative treatment can include these triptans: Zolmitriptan at a dose of 2.5mg taken every 8 -12 hours or Frovatriptan 2.5mg taken every 12 hours for 2 days before until 3 days after bleeding starts.

What to do in an acute migraine attack?

In an acute migraine attack, taking the pain killers, and anti-sickness medication and your choice of triptan as soon as possible, with a small can of fizzy drink can help, and to take these regularly through the attack. During a migraine attack, some body systems are affected, and drugs are not so easily absorbed.

You can buy medications over the counter, speak with a pharmacist or your doctor for advice to ensure it is safe to take these medications. Options for acute treatment include 900mg soluble aspirin every 8 hours, 400-600mg ibuprofen every 8 hours or 500mg Naproxen every 12 hours.

If using simple analgesics like aspirin, ibuprofen or paracetamol for acute treatment, talk to your Dr about add an anti-sickness tablet (e.g. prochlorperazine, metoclopramide) even if you are not suffering from nausea or vomiting as it improves gastric motility/drug absorption.

Triptans: These could be taken orally or nasally, and if they are not effective then an alternative triptan can be tried or it can be taken in a different way. There are 7 different triptans. Triptan medications are not usually effective during the aura phase, but some people find that aspirin can be helpful.

Look at the different Triptans, these are often taken in doses too low or not often enough to be effective.This Headsup podcast talks about the 7 different Triptans to help you decide with your Dr which might be right for you: Headsup podcast, all you need to know about Triptans (episode 5)

What is a medication overuse headache?

It is possible to have headaches which are actually caused by the amount of painkillers taken to treat a headache. It’s very important to avoid medication overuse: unlike other headaches and pain conditions, regular use of short-term acute or rescue treatments for migraine attacks can trigger more attacks. This is known as medication overuse headache.

How much medication is too much? Advice from the National Migraine Centre is that a general rule of thumb would be to limit consumption over three months of head pain to:

  • ten days a month of regular over-the-counter painkillers (such as aspirin, paracetamol, or ibuprofen)
  • ten days a month of triptans
  • always avoid opioids or combination drugs (eg paracetamol with codeine).

National migraine centre: Acute treatment and medication overuse headache (episode 8)

National migraine centre: medication overuse headache fact sheet

I’m having frequent migraine attacks, what can I do? Preventer treatment for frequent migraine attacks

Your GP can prescribe some medication to help prevent migraine if you are suffering from four or more migraine attacks each month. They include Propranolol, Candesartan, Topiramate and Amytriptyline. They would be slowly weaned up to maximum tolerated dose over 6-8 weeks and then assessed to see if they are effective. If they are effective they can be slowly reduced to stop after 6-12 months.

There are other treatments now available. This link The National migraine centre: The latest treatments for migraine shows you about these treatments which include:

  • Anti-CGRP medication: there are two classes of CGRP inhibitors, the injectable monoclonal antibodies (MABS) and the oral CGRP receptor antagonists (GEPANTS)
  • Nerve blocks
  • Botox.
How can lifestyle help?
  • Trying to manage and minimise your triggers can help.
  • Having a healthy lifestyle with regular exercise and optimising your weight can help if you suffer with migraine.
  • A diet high in omega-3 (oily fish) has good evidence that it is effective
  • Acupuncture for episodic migraine.
  • Aim for regular routine with sleep, meals, hydration and exercise.
  • Promote relaxation e.g. yoga 
  • Cognitive Behavioural Therapy can be helpful
What supplements might help?

There is some evidence that taking supplements can help: Riboflavin B2 400mg daily and will turn your urine bright yellow; Magnesium Glycinate 400-600mg daily and co-enzyme Q10. It is recommended to take these supplements for 3 months at least before you may see an improvement. Check with your Dr before taking supplements to be sure they are safe for you and listen to and read the information below.

This Headsup podcast gives further information: Migraine prevention, lifestyle and supplements (episode 6)

National migraine centre information looking at the evidence for alternative therapies for treating migraine

Fact sheets to help:

Books: Managing your Migraine by Dr Katy Munro

References: National Migraine Centre, BMS Migraine article, The Migraine Trust, The Headsup Podcast and NB Medical 2024

This article is for information only, please speak to your doctor to discuss the correct individual treatment for you.

Dr Carys Sonnenberg June 2024 Rowena Health

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