In some Asian cultures, the season of life during menopause is called “second spring.” It represents a time of renewed energy and self-care. But your second spring symptoms might feel like the winter blues or blazing summer. Add migraine to the mix, and you may wonder how to manage this season of life.
What Is Menopause?
Thanks to a few celebrities (and comedic influencers), there’s been more talk than ever about menopause. It has grown from our mothers’ and grandmothers’ “hush-hush” topic to one with more coverage than ever before. Contrary to some beliefs, menopause is a moment in time. It is defined as not having your menstrual cycle (period) for 12 months back-to-back. Everything before that is perimenopause. Everything after that is called postmenopause.
While your doctor may run blood tests to check your hormone levels, menopause is noted based on your symptoms and tracking the last day of your period.
Don’t forget the P
While menopause gets the main stage, it’s really perimenopause (which can last anywhere from 8 to 10 years) that starts the show.
Most women start having symptoms in their 40s, but it can start earlier due to other health factors. Signs you’re in it or on your way include:
- Irregular periods
- Hot flashes
- Night sweats
- Vaginal dryness
- Urgency (need to pee often)
- Insomnia (trouble falling or staying asleep)
- Mood swings, irritability, or depression
- Dry skin, eyes, or mouth
- Breast tenderness
- Headaches
The changes in your hormones (basically a drop in estrogen and progesterone) can cause these and other symptoms, such as heart palpitations, joint pain, a decline in libido (sex drive), hair thinning, weight gain, and brain fog. Hormonal swings, especially in perimenopause, can increase and cause symptoms.
The hormone factor
So, what happens to the body during perimenopause? Simply, your ovaries are rushing to close shop. They’re releasing hormones irregularly while also releasing fewer eggs (the opposite of ovulation).
“For many patients, the wide fluctuations in their female hormones during perimenopause and menopause can trigger an increased frequency of headaches,” says Cathleen “Cat” Brown, DO, a board-certified OB/GYN and medical director of Winona, a national menopause telehealth provider.
Because migraine hormone drivers like estrogen and progesterone are out of balance during the years leading up to menopause, your migraine attacks may increase. But there is a soft light at the end of the migraine tunnel. “Many patients will see a decrease in their migraine episodes when their hormonal fluctuations stabilize,” Brown says. “For some women, this can happen after they start hormone therapy, and for others, they can see a significant decrease after menopause.”
Such was the case for Mo Clark-Morris, 49, a process and compliance senior manager in Los Angeles. “I’ve had migraines with vision issues since I was in college,” Clark-Morris says. She started getting intense migraine attacks in high school, and vision issues prompted doctors to order scans of her brain. It showed no tumor, but vision issues continued.
Clark-Morris says she had the classic migraine with aura symptoms — seeing a halo, light sensitivity, and nausea. Much to her surprise, her migraine attacks have become more manageable and easier to spot these days. “They used to be more unpredictable, but now my vision changes are a sign that a migraine is approaching.”
Despite having classic menopause symptoms like hot flashes and some less common ones like itching, Clark-Morris says her migraine attacks have eased up. “I am grateful that my migraines have calmed down a bit. I still get them, but they are rare.”
Unfortunately, for some people, migraine can get worse with age. Carmel Cochrane, 67, a training and development consultant in Los Angeles, saw a rise in her migraine attacks after menopause — and a bout with breast cancer — in her mid-40s. “My migraines got worse after breast cancer treatment,” Cochrane says. “I’m not sure if there is a connection, but they did not go away. I have about five migraines a month with aura.”
Despite vision issues and having a hard time walking at times, Cochrane says she pushes through like many women her age. “I think a lot of women — especially Black women — are taught to just push through and deal with it in silence,” Cochrane says. Raising a family and working a full-time job also makes things difficult for women with menopause symptoms and migraine. “You don’t want to complain because you want to keep your job,” she says. “My solution is normally to go to a dark room and rest. I haven’t taken much medication because I’m nervous about the long-term impact on my liver and kidneys.”
What Is Estrogen Withdrawal?
How do hormones play a factor in migraine? There’s a myth that your migraine attacks go away once you enter menopause. But that isn’t necessarily true. Hormonal swings can actually increase your migraine episodes.
Terms like estrogen withdrawal explain the dramatic drop in estrogen that happens after stopping hormone replacement therapy, if your ovaries are removed, or during menopause. Because there is often a sudden rise and fall of estrogen during menopause, you may actually have more migraine attacks until things settle down. This may explain why pregnant women often have a break in migraine as estrogen rises dramatically and then stays high for the pregnancy.
Some studies suggest a lower pain tolerance as estrogen drops — possibly making migraine attacks more troublesome than earlier in life.
But remember, the menopause lasts a certain number of years. It’s a transition where levels eventually get stable.
How Your Migraines May Change
Not only might your migraine attacks have a temporary uptick during perimenopause, but they can also change during this phase. You may have more dizziness or get vestibular migraine attacks, which can come with nausea, vomiting, and balance problems. The timing of your migraine attacks may shift to early mornings, possibly because of sleep issues. In some cases, a certain gene may trigger migraine attacks that wake you up at the same time each night.
You may not have had migraine with aura in your younger years, but you may notice the visual changes — such as seeing flashing lights or zigzag lines — as you get older. Or your migraine attacks may stay the same. Each person is different, and so will your migraine attacks be as you age.
A Word on Sleep
If you feel that getting good sleep is becoming harder as you age, you’re not alone. More than 40% of women in their perimenopause era report sleep problems.
But problems can range from trouble falling asleep or staying asleep range from trouble falling or staying asleep to poor rest caused by night sweats, or even developing sleep apnea, a condition where your airways are blocked during sleep, lowering the amount of much-needed oxygen in the body.
All these things are caused by hormonal shifts. Estrogen controls body temperature, and as it drops during menopause, your temperature (enter night sweats) can go up. Estrogen also supports the “feel-good” hormones in your body, such as serotonin, and when low, can make you grouchy — not a good factor for sleep. Also, a drop in progesterone, which has natural calming effects, makes it harder to fall asleep. If that’s not enough to mess up a good night’s sleep, the chemical cortisol (which tells your body it’s time to fight or flee a tiger) is higher during menopause.
“Probably the most important lifestyle factor is sleep quality,” Brown says. “When women don’t get enough sleep or restful sleep, they can be more prone to headache episodes, especially migraines.”
So, what does an aging girl have to do to get a good night’s sleep? Talk to your doctor about hormone replacement therapy or other things, such as magnesium or melatonin, which can help you sleep. Practice good sleep hygiene — sleep in a cool, dark room; avoid caffeine, alcohol, and eating too close to bedtime; and turn off things that ping and ding. Certain products, such as bed linens or pajamas with special cooling technology, may help.
Getting Reacquainted With Migraine
If you’ve lived with migraine for years, the phase of menopause may force you to get to know your migraine once again. They can change, increase, decrease, or respond differently to treatment. Thankfully, some things can help.
Acute (during a migraine attack) treatment
If you’re having a migraine attack, your options currently are oral tabs, injections, or nasal sprays. Your doctor may refer to this type of treatment as ‘abortive treatment’ as it’s designed to stop a migraine episode in its tracks.
- Oral tabs. A migraine medication category called triptans can work quickly and effectively, especially if taken with a nonsteroid anti-inflammatory drug (NSAID) such as ibuprofen or naproxen. Calcitonin gene-related peptide (CGRP) blockers are another option, especially if you can’t take triptans because of a history of high blood pressure, heart attack, or stroke.
- Injectables. These work even faster than triptans, but they aren’t right for everyone. Talk to your doctor about your options.
- Nasal sprays. In terms of how fast they work, nasal sprays land somewhere between oral tabs and injections.
Preventive treatment
Doctors may talk to you about preventive treatment if you have more than four migraine headaches per month. This type of treatment is taken daily or a few days leading up to hormone migraine triggers (like getting your cycle). Options include:
- NSAIDs. They can be taken when having a migraine attack or during the five to seven days leading up to your period to prevent a migraine.
- Hormone replacement therapy (HRT). Adding back the hormones like estrogen and progesterone that naturally decline during menopause years can help. Estrogen comes as a pill, vaginal gel, or patch. Progesterone is available as a cream or pill, and both may be prescribed to help with your overall menopause symptoms. However, more research is needed to understand if HRT decreases or increases migraine episodes in some women. Be sure to talk to your doctors about HRT if you have migraine with aura, as some studies show a slight risk of stroke when on HRT. Also, hormone therapy isn’t right for all women, like those who have had certain types of breast cancer. Keep in mind, HRT was not developed to treat migraine.
“Ultimately, it comes down to risk vs. reward,” Brown says. “If the benefits we see from the hormone therapy outweigh the small risk of taking the HRT, then we continue treatment. On the other hand, if a patient starts noticing an increase in the frequency of auras and or migraines while having only limited relief of menopausal symptoms, then sometimes the risks outweigh the reward and we may have to discontinue hormone therapy.”
- Triptans. Like NSAIDs, triptans can also be used to prevent migraine attacks. Talk with your doctors about the right dosage for you, as too much headache medication can actually cause a migraine attack.
- Magnesium. Many people are low in magnesium. Researchers say only half of us are getting the right amount. It can have calming properties, such as improving sleep and fighting migraine attacks. So, you might consider taking a daily supplement. You can also take magnesium in the days leading up to your menstrual cycle if you still have regular periods.
Lifestyle Triggers
If you’ve been living with migraine for years, then you may know that many things in daily life can trigger migraine attacks. Many of these approaches may continue to work as you move into menopause. The American Migraine Association uses the acronym SEEDS — Sleep, Exercise, Eat, Diary, and Stress — to help you remember key migraine triggers.
Sleep. Talk to your doctor about ways to improve your sleep, which can take a hit during menopause.
Exercise. Doing regular low-impact exercises, such as walking, yoga, gardening, or water aerobics, can help lower the frequency of migraine attacks.
Eat (food and water). Eating regular meals (not missing meals) and staying hydrated throughout the day can help you ward off migraine. Watch out for certain foods like chocolate, too much caffeine, and alcohol, which can trigger migraine.
Diary. Because migraine symptoms vary from person to person, keeping a journal of your migraine symptoms and triggers can help you and your doctor figure out the best treatment.
Stress. Stress can trigger migraine attacks. Perimenopause and menopause can be a stressful time in life. Focus on self-care, talk to a therapist, and find things that bring you joy.
Talk to your doctors about treatments for your menopause symptoms and your migraine attacks. With support from your doctors, friends, and family, you too can have a beautiful second spring.
