Migraines and menopause: why perimenopause is the worst time
Have your migraines become more frequent and less predictable over the past two or three years? It is not your age, and it is not that you cope less well. In the American AMPP survey of 3,664 women with migraine, very frequent headaches (at least ten days per month) affected 8.0% of women still cycling normally versus 12.2% of women in perimenopause. The mechanism is counterintuitive: it is not the lack of estrogen that triggers the attack, it is the drop. A placebo-controlled trial with estradiol gel demonstrated it by simply shifting the attack by five days. The video also explains aura and the warning signs that require calling emergency services, vascular risk with its absolute and not only relative risk, and above all the most widespread confusion: combined estrogen-progestin contraception is not recommended in migraine with aura, but transdermal menopause hormone therapy at physiological doses is not contraindicated. In French with English subtitles.
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What you will understand
Have your migraines become more frequent and less predictable over the past two or three years? It is not your age, and it is not that you would cope less well. It is documented, and it has a name: perimenopause.
In the American AMPP survey, which followed 3,664 women with migraine of average age 46, very frequent headaches (at least ten days per month) affected 8.0% of women still cycling normally, versus 12.2% of women in perimenopause. These are group averages: it does not mean every woman will see her migraines increase.
The mechanism is counterintuitive, and it is what explains all the rest. It is not the lack of estrogen that triggers the attack, it is the drop. A double-blind placebo-controlled trial demonstrated it elegantly: applying an estradiol gel reduced migraine days during application, but increased them in the five days following the stop. The attack had not been avoided, it had been shifted.
That is also why, in many women, things improve after menopause, once the fluctuations are over, except after a surgical menopause, where the withdrawal is abrupt.
The video then addresses aura, what exactly it is, how to distinguish it from a stroke, and the signals that require calling emergency services without delay. Then vascular risk, always with its absolute risk and not only its relative risk.
Finally, the most widespread confusion, and probably the most concrete service of this video: many women with migraine with aura are told that "hormones are forbidden to them". That is true for the combined estrogen-progestin pill. It is not true for menopause hormone therapy at physiological doses by the transdermal route. This confusion deprives women of an option they are entitled to.
The key points to remember
- Migraine is a neurological disease, not a bad headache. The distinction changes management.
- It is not the low estrogen level that triggers the attack, it is the drop. Hence the worsening during perimenopause, when the fluctuations are strongest.
- AMPP survey, 3,664 women: headaches at least ten days per month in 8.0% of premenopausal women versus 12.2% in perimenopause.
- A placebo-controlled trial with estradiol gel reduced migraines during application and increased them in the five days after stopping: the attack is shifted, not suppressed.
- After menopause it often improves, but not for everyone, and rather less so after a surgical menopause.
- Aura settles in gradually over 5 to 20 minutes and then recedes. Onset within seconds is not an aura: it is an emergency.
- Migraine with aura and vascular risk: the relative risk is about doubled, which represents 18 additional events per 10,000 women per year. Migraine without aura was associated with no increase.
- Combined estrogen-progestin contraception is not recommended in case of migraine with aura.
- Menopause hormone therapy, on the other hand, is not contraindicated by aura: transdermal route, minimum effective dose, continuous progestogen. It is a shared medical decision, and never a treatment for migraine.
- Watch out for medication-overuse headache: treating attacks too often keeps the headaches going.
Video chapters
- 0:00 The evening that tips over
- 0:56 Migraine or headache: they are not the same
- 1:56 Why women: the drop in estrogen
- 2:48 What the AMPP study shows
- 4:31 The demonstration with estradiol gel
- 5:26 After menopause, it often improves
- 6:16 Aura, explained simply
- 7:08 The signs that require calling emergency services
- 7:59 Aura and vascular risk: the two figures
- 8:54 Contraception: what is not recommended
- 9:48 MHT: what you are wrongly told
- 10:43 Treating the attack without falling into the trap
- 11:36 Moving, sleeping, recap
The scientific sources cited
Every claim in this video rests on a verified reference. Here is the complete list, with the PubMed links. These studies are covered in detail in the written and sourced version of this topic.
- Martin VT et al., Headache, 2016 (AMPP survey). PubMed 26797693
- Ripa P et al., Int J Womens Health, 2015. PubMed 26316824
- Allais G et al., Neurol Sci, 2015. PubMed 26017518
- Pavlović JM et al., J Headache Pain, 2015. PubMed 25902814
- Neri I et al., Maturitas, 1993. PubMed 8412841
- MacGregor EA et al., Neurology, 2006. PubMed 17190936
- MacGregor EA, Curr Pain Headache Rep, 2009. PubMed 19728968
- MacGregor EA, Post Reprod Health, 2018. PubMed 28994639
- Kurth T et al., JAMA, 2006 (Women's Health Study). PubMed 16849661
- Magalhães JE et al., Headache, 2018. PubMed 30117565
- Sacco S et al., J Headache Pain, 2017. PubMed 29086160
- Ornello R et al., Expert Rev Neurother, 2020. PubMed 32056462
- Varkey E et al., Cephalalgia, 2011. PubMed 21890526
- Okoli GN et al., Can J Neurol Sci, 2019. PubMed 30764890
Frequently asked questions
Why are my migraines getting worse now, when they were manageable before?
Because perimenopause is the period when estrogen fluctuates the most, with rapid and unpredictable drops. And it is the drop that triggers the attack, not the low level in itself. That is also why the rhythm becomes less predictable than in the days when your cycles were regular.
Will it stop after menopause?
Often, yes: once the hormonal fluctuations are over, many women see their migraines space out. But it is not a rule, and the improvement seems less clear after a surgical menopause, where the hormonal drop is abrupt.
I have migraines with aura: is hormone therapy forbidden to me?
That is the most frequent confusion, and it is a costly one. What is not recommended in case of migraine with aura is combined estrogen-progestin contraception, based on ethinylestradiol. Menopause hormone therapy, at physiological doses and by the transdermal route, is not contraindicated by aura itself. The decision belongs to the doctor who knows your file, and the treatment is stopped if the aura reappears or worsens.
Does migraine really increase cardiovascular risk?
For active migraine with aura, a large follow-up study finds a relative risk about doubled. It must be read together with its absolute risk: that corresponds to 18 additional events per 10,000 women per year. For migraine without aura, no increase was found. Smoking is here a factor you can act on.
When should you call emergency services?
A headache that peaks in less than a minute, a sudden deficit (drooping face, an arm that no longer responds, slurred speech), a first aura after 50, an aura lasting more than an hour or always on the same side, fever with a stiff neck, a headache after a head injury, or a progressive worsening: call immediately. 15 or 112 in France, 911 in Canada.
Can exercise replace a preventive treatment?
One trial compared exercise three times a week, relaxation and a preventive treatment, with no significant difference between the three. But the sample was small, and an absence of difference is not proof of equivalence. Moving helps; it does not replace medical advice.
Do perimenopausal migraines justify particular follow-up?
They deserve at the very least to be documented. Keeping a diary of attacks, noting the date, duration, intensity and treatments taken, allows the doctor to distinguish a worsening linked to the hormonal transition from another mechanism, and to spot possible medication overuse. It is also what makes an informed decision about a preventive treatment possible, rather than managing attack by attack.
Should you see a neurologist or a gynecologist?
The two perspectives complement each other, and the order matters little. Your family doctor often remains the best starting point: they know the whole file, including cardiovascular history and current treatments, which weigh in the decisions. They will refer you for specialist advice if the attacks become frequent, if the aura changes in character, or if a preventive treatment is being considered.