Migraine in Perimenopause and Menopause

Migraine during perimenopause and menopause is best managed by a headache specialist, often in collaboration with an OBGYN.

Headache disorders should be primarily overseen by a specialist, who can provide expert guidance on migraine treatment and prevention. If hormone-based strategies are needed, the headache specialist and OBGYN should work together to tailor a comprehensive, individualized plan that addresses both hormonal and migraine-related aspects of care.

—Dr. Natbony

To get an accurate diagnosis of perimenopausal migraine attacks, I recommend focusing on your history and symptoms rather than relying on blood tests or a complete hormone panel.

Perimenopause is a clinical diagnosis, typically based on tracking changes in your periods, migraine patterns, sleep, and other symptoms like hot flashes or brain fog.

Hormone panels are generally not reliable for diagnosing perimenopause, as hormone levels can fluctuate significantly even within a single day. Keeping a symptom diary is often the most helpful tool for you and your doctor.

—Dr. Natbony

Yes, there are specific types of hormone replacement therapy (HRT) considered safer for women with a history of migraine.

I recommend a transdermal estrogen (such as an estradiol patch) over oral estrogen because it provides more stable hormone levels and is generally associated with fewer migraine triggers and lower risk profiles, especially for those with migraine with aura. I also advises using the lowest effective dose of estrogen and, if needed, adding natural progesterone for women with a uterus.

An individualized, precision-based approach is important, considering each patient’s unique risk factors and response to treatment.

—Dr. Natbony

Beyond hormone replacement therapy (HRT), there are several preventive and acute medication options for managing migraine during the menopausal transition.

For prevention, there are standard migraine preventives such as beta blockers, CGRP monoclonal antibodies (like Aimovig or Emgality), and Botox can be effective. I often recommend layering treatments—meaning adding an additional preventive if one alone is insufficient.

For acute treatment, standard migraine-specific medications such as triptans, CGRP receptor antagonists, and nonsteroidal anti-inflammatory drugs (NSAIDs) are frequently used.

Supplements like magnesium (especially magnesium glycinate), CoQ10, and vitamin D can also play a role, along with FDA-cleared medical devices (such as Nerivio, Cefaly, and gammaCore) to further support migraine management.

Each treatment plan should be personalized and, if possible, developed in partnership with a headache specialist.

—Dr. Natbony

Supplements such as magnesium, CoQ10, and vitamin D can be valuable components of a comprehensive migraine management plan for women in menopause.

Magnesium—especially magnesium glycinate, for its bioavailability and tolerance—can help stabilize hormonal fluctuations, ease sleep issues, and potentially reduce migraine frequency, particularly for those experiencing hormonal changes.

CoQ10 and vitamin D are also used as preventive options; while there is no specific evidence that they are more effective during menopause compared to other stages, they are generally safe and may support overall health.

Supplements typically offer moderate benefit, so they are best used alongside other preventive and acute treatments, rather than as a sole therapy—especially for those with more frequent or severe migraine attacks.

—Dr. Natbony

Yes, there are several approaches you can take during perimenopause to help manage migraine attacks:

Medication adjustments: Standard migraine preventives (like beta blockers, CGRP monoclonal antibodies, gepants, or Botox) can be used, and sometimes layering or adjusting medications is necessary if migraine attacks become more frequent or severe.

Supplements: Magnesium (especially glycinate), CoQ10, and vitamin D may provide moderate preventive benefit, particularly magnesium for those experiencing hormonal fluctuations or sleep issues.

Lifestyle changes: Regular sleep, hydration, healthy meals, and consistent exercise are important foundational lifestyle factors for migraine management.

Mind-body practices: Techniques such as yoga, meditation, and biofeedback can help reduce migraine frequency and improve well-being.

Alternative treatments: Acupuncture may help with hot flashes and migraine, though it is not a guaranteed cure-all. Herbal remedies for hot flashes (like black cohosh) may alleviate menopause symptoms, which could indirectly help with migraine triggers, though evidence for their effect on migraine itself is limited.

Medical devices: FDA-cleared devices like Nerivio, Cefaly, and gammaCore can be helpful additions to your migraine “toolbox.”

A personalized approach, ideally created in collaboration with your healthcare providers, will help you find the mix of treatments and lifestyle changes best suited to your needs during perimenopause.

—Dr. Natbony