Headaches and Migraines in Perimenopause

Migraines are the second leading cause of disability for women worldwide. Not only do migraines have a strong genetic predisposition, but they also have a strong hormonal influence. Boys and girls have similar rates of migraine until puberty, and then migraines become three times more common in women. Migraine patterns can change along with the menstrual cycle, pregnancy, perimenopause, and menopause.

If you already experience migraines, perimenopause can increase the frequency and intensity. The hormonal changes of perimenopause can also trigger the new onset of migraines in women who’ve never had them before. Either way, you’ll want to keep reading as we discuss the connection between hormones and migraines and integrative approaches to prevent and treat them.

This article will discuss:

• Changes in estrogen and progesterone in perimenopause and the effect on migraine
• Perimenopausal migraine patterns
• Migraines in menopause
• The bucket analogy
• Integrative strategies to manage migraine in perimenopause

The Migraine-Perimenopause Connection

Migraine affects 14% of people worldwide and 10 to 29% of women during perimenopause.  The brain undergoes a significant reorganization and adjustment to the fluctuating and eventually declining hormone levels during this time. Changes in hormones affect the migraine process, increasing vulnerability to migraine attacks and pain.

Fluctuating hormone levels, primarily estrogen decline, can trigger migraine in what’s called the estrogen withdrawal hypothesis. Evidence suggests levels of estradiol, the primary estrogen in cycling women, below 45-50 pg/mL is enough to trigger migraine onset. Not only do estrogen levels fluctuate more in perimenopause and eventually decline in late perimenopause, but cycles can become irregular with more opportunities for estrogen dips.

The brain contains abundant estrogen receptors in areas associated with migraine and pain processing. Women with migraines have higher levels of circulating CGRP (calcitonin gene-related peptide), which is involved in migraine pain and modulated by estrogen. Estrogen is also anti-inflammatory; low estrogen can mean increased inflammation.

Declining progesterone also contributes to migraine pain, and progesterone is often the first hormone to decline in perimenopause. Progesterone is calming, sleep-supportive, and protective against migraines.

Other perimenopausal symptoms, like sleep disturbances and mood changes, can also contribute to worsening migraines during this transition.

Perimenopausal Migraine Patterns

For most of the perimenopausal transition, women still have a menstrual cycle, although the cycle becomes increasingly irregular over time. Since the natural hormonal fluctuations of the menstrual cycle can be more dramatic or intensified in perimenopause, you may see migraine patterns with your cycle, such as:

• Pure menstrual migraine – these migraine attacks occur in the late luteal phase, leading up to the period. They affect around 7% of perimenopausal women with migraines.

• Menstrual-related migraine – This migraine pattern includes menstrual migraines before the period and migraines at other times of the cycle (such as after the period or around mid-cycle). Over 70% of perimenopausal women with migraine fit into this pattern.

• Non-menstrual migraines don’t seem to correlate with the menstrual cycle and may have stronger triggers besides changing hormones.

Most women in perimenopause experience migraine without aura, although aura affects about 25% of women and is more associated with high estrogen vs. estrogen withdrawal. Estrogen dominance can occur during perimenopause.

The Good News

For women who experience a robust hormonal influence with migraine pain, the good news is that the perimenopausal migraine increase is temporary. Many women experience a dramatic decline or total cessation of migraines after menopause when hormones are stable instead of constantly cycling or fluctuating. Additionally, for women who choose hormone replacement therapy in menopause, you can work with your TārāMD provider to keep hormone levels stable.

Other Migraine Triggers

Hormones aren’t the only migraine triggers. Understanding other triggers can help lessen the intensity of hormonal swings on your symptoms.

Let’s use the bucket analogy. Each woman with migraines has a bucket that fills with various triggers throughout the day. When the bucket overflows, a migraine attack occurs.

The bucket analogy helps us understand why sometimes eating a specific food trigger causes a migraine, but other times, you seem to tolerate it. It depends on what’s already in your bucket.

Additionally, you might have a bigger or smaller bucket than someone else. And your bucket might become smaller in perimenopause. Because of the changing physiology of your body through this transition, you can be more sensitive to triggers.

Some migraine triggers, like hormones and barometric pressure change, are not within our control. But by controlling the triggers that we can, we can keep our bucket less full, so when a storm rolls in or estrogen drops, it doesn’t overflow.

Some migraine triggers that may be within your control could include:

• Food triggers such as high histamine foods, high triamine foods, gluten, artificial sweeteners, caffeine, alcohol, MSG, aged foods, etc.
• Florescent, bright, or flickering lights
• Strong fragrance or chemical smells
• Stress (some stress management is within our control)
• Skipping meals and low blood sugar
• Dehydration, not drinking enough water
• Poor sleep habits
• Nutrient deficiencies

The goal is to identify what’s within your control and manage it. Your bucket will likely still overflow, but it may be less often and less intense. Additional integrative approaches are also available.

Integrative Approaches for Migraine in Perimenopause

Integrative medicine combines the best of allopathic medicine and holistic strategies to treat acute migraine attacks and work to prevent them in the first place. Let’s look at some of the tools in the integrative toolkit:

• Migraine medications have evolved dramatically over the last decades, offering new options, including CGRP inhibitors that are more effective and have fewer side effects than previous generations of migraine medications. Medications can be lifesavers to have on hand for the migraines you can’t prevent. It can take some experimentation to determine what works for you as you consult with your provider.

• Perimenopause hormone therapy – Your hormonal picture and needs in perimenopause can be highly individual, and understanding how your migraines relate to your cycle is an excellent first step. Some women will find migraine support with bioidentical progesterone to help offset declining progesterone in perimenopause and balance estrogen.

While estrogen therapy doesn’t have a direct anti-migraine effect, you can use bioidentical estrogen (estradiol) to cushion estrogen dips through the cycle and get the anti-CGRP and anti-inflammatory benefits. Always work closely with your TārāMD provider for guidance and monitoring.

• Keep a migraine diary – Use your period app or calendar to track migraines along with other potential triggers. This strategy can help you identify patterns to relay to your doctor and potential migraine triggers.

• Try an elimination diet – Work with your TārāMD nutritionist to design a personalized elimination diet to help identify potential food migraine triggers. The first step is to eliminate suspicious foods for a period of time. Then, you’ll add them back into the diet one at a time while monitoring for migraines (and other symptoms). It’s helpful to have an abortive medication on hand for this process.

Other therapeutic diets such as a ketogenic diet, high omega-3 diet, low-glycemic diet, methylation-supportive diet, and others have data for improving migraine. Additionally, eating to keep your blood sugar stable may have benefits for both migraine and perimenopause. Your nutritionist can help you determine the best approach to try and ensure you continue to meet your nutrient needs while shifting eating patterns.

• Consider supplements – Various supplemental nutrients and herbs may support migraine pathways. Options to consider include:
  • Magnesium
  • Vitamin E
  • Riboflavin (vitamin B2)
  • Iron (if iron-deficient)
  • Melatonin
  • Ginger
  • butterbur
  • Feverfew
  • Vitex
  • Phytoestrogens

Work with your TārāMD team for nutrient testing and personalized supplement recommendations and dosages.

• Increase Oxytocin – Oxytocin is a feel-good hormone of connection and love, naturally high during labor, postpartum, and breastfeeding to facilitate uterine contractions, milk let down, and boding. Interestingly, oxytocin production is regulated by estrogen and may have an anti-migraine and anti-pain effect. Some research has looked at an oxytocin nasal spray for migraine relief. Natural ways to increase oxytocin include:
  • Cuddling
  • Hugging
  • Massage
  • Sex
  • Petting an animal
  • Yoga
  • Listening to music
  • Social connections
  • Meditation

These strategies might not work when a migraine attack is coming on, but when practiced consistently, they may help lessen migraines over time.

Migraine is a complex disease, and there isn’t a quick fix or single intervention for those who suffer. As migraine attacks intensify and change throughout perimenopause, it requires a comprehensive, integrative approach to prevent and treat pain and other symptoms. Many women will benefit from lifestyle changes, identifying environmental triggers, supplements, and medications. All of this can help prevent the migraine bucket from overflowing as often, significantly improving the quality of life through the perimenopausal transition.

References

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2. Pavlović J. M. (2018). Evaluation and management of migraine in midlife women.Menopause (New York, N.Y.), 25(8), 927–929.
3. Ornello, R., De Matteis, E., Di Felice, C., Caponnetto, V., Pistoia, F., & Sacco, S. (2021). Acute and Preventive Management of Migraine during Menstruation and Menopause.Journal of clinical medicine, 10(11), 2263.
4. Spekker, E., & Nagy-Grócz, G. (2023). All Roads Lead to the Gut: The Importance of the Microbiota and Diet in Migraine.Neurology international, 15(3), 1174–1190.
5. Gazerani P. (2020). Migraine and Diet.Nutrients, 12(6), 1658.
6. Godley, F., 3rd, Meitzen, J., Nahman-Averbuch, H., O'Neal, M. A., Yeomans, D., Santoro, N., Riggins, N., & Edvinsson, L. (2024). How Sex Hormones Affect Migraine: An Interdisciplinary Preclinical Research Panel Review.Journal of personalized medicine, 14(2), 184.