If you’re a woman with episodic migraine, you may have figured out a treatment regimen after years of trial and error. But when you hit midlife, what worked before may not keep working. Changing your routine can be tough — how do you sort through all the available treatments?
Your migraine attacks are considered episodic if you have up to 14 headache days per month. If you have more than that, your migraine is considered chronic.
Women are three times more likely than men to have migraine, and the pattern can be tied to hormone changes throughout your life. Headaches are likely to start around the time of your first period and get worse through your 30s. After menopause, some women find their migraine improves dramatically. But those middle years — between 45 and 64 — can be tough to manage.
“Unfortunately yes, migraines can often worsen during perimenopause and even persist after menopause,” says Maggie Wuang, MD, the general neurology division chief at the Weill Institute for Neurosciences, University of California, San Francisco.
You may need to change the way you deal with your migraine — including trying new treatments — in this phase of your life.
First, Gather Information
If your migraine attacks seem to be getting more serious or more frequent, it’s helpful to track those changes using a headache diary. The National Headache Foundation has a form you can download, or you can create your own.
Several apps are also available to help you chart your headaches using your smartphone.
What you learn can help guide your treatment.
Check in With Your Doctor
If your migraine attacks are getting worse, schedule an appointment with your doctor.
They may start with a list of questions:
- Are your headaches interfering with work and your daily life?
- Are your headaches more frequent or severe — or both?
- Are over-the-counter medicines not working? Do you worry you're taking them too often?
- Have you gone to the emergency room for a headache?
You shouldn’t just try to tough out worsening migraine attacks, Wuang says. “If you are making accommodations or altering your life and activities because of migraines, you should make a change.”
Meredith Vinger Roach, MD, medical director of the Virtual Headache Care Program at Baylor Scott & White Health, says that if you’re older than 50 and your headaches are getting worse, that’s a “red flag” symptom. “You need to have an MRI to make sure there’s not a neoplasm there.”
If an MRI does not show any suspicious growths, the next step is to review your current regimen.
You may rely on your primary care doctor or gynecologist to help manage your episodic migraine attacks. But that doctor may decide that it’s time for you to see someone who specializes in treating headaches. That may be a neurologist or a doctor who has advanced training in treating migraine.
Treating migraine headaches is time-consuming for doctors, Roach says — time that a primary care doctor with a large caseload may not have. If you hope to start a new treatment, your insurance company may require records of all the treatments you’ve already tried, any side effects you had, and proof that those drugs aren’t working any longer. You generally have to try a treatment for three months before an insurance provider will agree that it’s not working and approve moving on to another drug.
Types of Migraine Treatment
Migraine treatments are divided into two broad categories: acute and preventive.
Acute medications are things you take when you’re having a migraine. They’re designed to stop the pain and keep your migraine from getting worse.
Preventive medications are things you take on a regular schedule that can cut down the number of migraine attacks you have and how serious they are.
Over-the-counter (OTC) acute medications
Most people with migraine have tried OTC pain relievers at some point. OTC drugs to treat migraine include:
- Acetaminophin
- Aspirin
- Ibuprofen
- Naproxen
Some OTC medicines marketed for migraine combine a pain reliever with caffeine.
OTC drugs are inexpensive and easy to find. But if you’re relying on them for migraine relief, you should be aware of the drawbacks. Follow the recommended dosage — taking too much acetaminophen, for instance, can damage your liver.
If you’re taking OTC pain relievers for more than two days a week, your headaches might even worsen, especially if you choose one that contains caffeine.
And it’s not just an issue of taking these medications for headaches. Joint pain from wear and tear worsens in midlife, and you may turn to OTC drugs for those problems. “If you’re taking Tylenol — whether for your headache or back, or something else — more than twice a week, you could be setting yourself up for Medication Overuse Headache,” Roach said.
If OTC drugs aren’t working for you, or you need to take them too often, your doctor may suggest switching to an acute prescription medication.
Prescription acute medications
Prescription medicines for treating your migraine pain fall into several categories.
Triptans block pain pathways in your brain. They come in several forms — including pills, nasal sprays, and shots. Drugs in this group include:
- Almotriptan
- Eletriptan (Relpax)
- Frovatriptan (Frova)
- Naratriptan
- Rizatriptan (Maxalt)
- Sumatriptan (Imitrex, Tosymra, others)
- Zolmitriptan (Zomig)
Dihydroergotamine is a nasal spray. Brand names include Migranal and Trudhesa. It works best when you take it right as a migraine attack begins.
Lasmiditan, a newer drug, comes in pill form. The brand name is Reyvow.
Oral calcitonin gene-related peptide (CGRP) antagonists are another newer type of acute migraine drug. These medicines are also called gepants. Examples include rimegepant (Nurtec ODT) and ubrogepant (Ubrelvy).
Intranasal zavegepant is another type of gepant. It’s a nasal spray and is sold under the brand name of Zavzpret.
Opioids and barbiturates are no longer commonly used for acute migraine treatment. You might be prescribed one of these medicines if you can’t take other drugs. But most people can find more effective options than these highly addictive medicines.
Anti-nausea drugs can be added to your regimen if your migraine causes nausea and vomiting. Options include chlorpromazine, metoclopramide (Gimoti, Reglan), and prochlorperazine (Compro).
Preventive medicines
When your migraine attacks become more serious or more frequent, it might be time to think about adding a preventive medicine. You have several options. Which one you and your doctor choose depends on many factors, including whether you have other underlying conditions such as depression, high blood pressure, or asthma.
Blood pressure medications used for migraine prevention include beta-blockers and calcium channel blockers. Drugs in this class include atenolol, nadolol, propranolol, and verapamil.
Antidepressants used to prevent migraine attacks might be tricyclic or selective serotonin reuptake inhibitors. Options include amitriptyline, nortriptyline, and venlafaxine.
Anticonvulsants for migraine prevention include divalproex sodium, gabapentin, and topiramate.
Botox injections for migraine are done every 12 weeks.
CGRP-targeted therapiesthat use monoclonal antibodies are available as a monthly injection you give yourself, a self-injection every three months, or an IV infusion every three months. Options include eptinezumab (Vyepti), erenumab (Aimovig), fremanezumab (Ajovy), and galcanezumab (Emgality).
CGRP-targeted therapies that are gepants include atogepant (Qulipta), a pill you take daily, and a version of rimegepant (Nurtec) you take every other day.
A new infusion drug for migraine is in the testing phase. It targets a different chemical in your brain — pituitary adenylate cyclase-activating polypeptide (PACAP).
Hormone replacement therapy
If fluctuating estrogen levels are causing your migraine attacks, it might seem as though hormone replacement therapy (HRT) could help. But the research on HRT and migraine is mixed.
“Hormone replacement therapy can sometimes improve or worsen the impact of headaches,” Wuang says. “The data on this is scarce, but seems to suggest that HRT might worsen migraines on a population level. However, this is complicated, and the effects of HRT can be indirect. For example, many individuals notice improvement in sleep with HRT, which can reduce a common migraine trigger.”
Roach says HRT is not a “first-line” treatment for worsening migraine, but it can help some women. “If they don’t have any contraindications, they don’t have a strong family history of breast cancer, then HRT is something that absolutely could benefit them.”
If you have migraine with aura, Roach says, you should not take HRT.
Neuromodulation treatment
This type of treatment uses a device to stimulate nerves or parts of the brain that are linked to migraine.
They can treat acute attacks and also be prescribed as preventatives.
You wear a device or hold it against a certain part of your body, and it sends electrical or magnetic impulses. Types of this device include:
- Cefaly
- GammaCore
- Nerivio
- Relivion MG
- Savi Dual
Alternative Treatments and Lifestyle Changes
You can combine medication with other approaches to manage your migraine. These paths are also options for someone who can’t tolerate medications or just wants to avoid them.
Alternative treatments that may help ease migraine include:
- Acupuncture
- Biofeedback
- Relaxation practices such as yoga
- Vitamins and supplements such as riboflavin (vitamin B2), magnesium, feverfew, butterbur, or coenzyme Q10
- Green light therapy
You can also make lifestyle changes that may help with your migraine. Sticking to a consistent sleep schedule is one example. Regular exercise also might improve your migraine, though for some people, a vigorous workout can trigger a headache.
How to Choose a New Approach
Whether you try a new prescription medication, start a preventative drug, or add an alternative treatment, always discuss with your doctor.
In midlife, you’re more likely to have other health issues that may influence what course you choose. If you have high blood pressure or cardiovascular disease, for instance, triptans aren’t a good choice for you. Lasmiditan is a safer alternative. Beta-blockers aren’t recommended if you have chronic obstructive pulmonary disease (COPD).
Research has linked CGRP drugs to high blood pressure, which might rule those medications out for you.
Other health issues common in midlife can also lead to worsening migraine attacks, such as sleep apnea, grinding your teeth (bruxism), and mood disorders. Sometimes, Roach said, one drug can help with multiple issues. “Amitriptyline is a great one,” she said. “You can find one drug that does two things, such as help depression and sleep, but also helps migraine.”
All of your doctors should be aware of your migraine. If you’re seeing a cardiologist, for instance, your headache history is important because people with migraine are more likely to have cardiovascular disease, although the reasons aren’t clear.
Knowing about your migraine can help all of your doctors give you the best care. For instance, a gastroenterologist may be able to prescribe a type of colonoscopy prep that will lower your risk of getting a migraine attack due to dehydration.
The best plan for managing your migraine might involve a combination of treatments. For instance, research shows that taking both triptans and nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen is more effective than taking either type of drug alone.
You may need a combination of acute and preventative medicines, and choose to add on alternative treatments to manage your migraine in midlife.
As Wuang put it, “There are many different types of treatment for migraine, and for people who struggle with frequent migraines, it makes sense to take a multimodal approach to treatment.”
