Women—Your Health Matters!
Perimenopause and menopause present significant challenges for women with migraine, primarily due to dramatic hormonal fluctuations that can trigger or worsen attacks. The instability of estrogen and progesterone levels during perimenopause often leads to unpredictable and more severe migraine attacks, especially for women who already experience menstrual migraine.
Diagnosis becomes complicated as symptoms such as hot flashes, sleep disturbances, and mood changes overlap with both migraine and the menopausal transition itself. Additionally, reliable treatment can be elusive, as hormone replacement therapies or other interventions may not work uniformly or could even make symptoms worse.
A proactive, personalized approach to care is key to preventing migraine progression and reducing its disruptive effects on women's quality of life.
Many thanks to Dr. Natbony for her help with this project and answers to questions.
Watch this video with Dr. Natbony as she discusses how perimenopause and menopause can impact migraine
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Women, do not to give up hope. Remember that migraine is treatable—even though the path can be challenging. No one should feel they have to simply “settle” for persistent symptoms as an inevitable part of aging or menopause.
"Your experiences and symptoms are real and valid. Seeking personalized care, exploring all available treatment options, and believing in the possibility of improvement are essential steps to living better with migraine at any stage of life."
—Dr. Natbony
Is it Migraine, Perimenopause or BOTH?
Bring this to your next doctor's appointment and ask your doctor to help you build a personalized plan for managing your migraine during perimenopause and menopause.
Migraine in Perimenopause and Menopause
General Questions
—Dr. Natbony
—Dr. Natbony
During perimenopause, it's estimated that about 60% of women experience a worsening of their migraine attacks. The remaining women may see their migraines stay the same or, less commonly, improve during this time, though exact percentages for these groups aren’t specified.
During menopause, around two-thirds (about 66%) of women see their migraine attacks improve. However, not everyone experiences relief—some women may see their migraine attacks stay the same or even worsen, particularly if their attacks are less hormonally driven. These patterns highlight the individual variability in how perimenopause and menopause affect migraine.
—Dr. Natbony
During perimenopause, hormonal fluctuations—especially irregular and rapidly changing levels of estrogen and progesterone—make migraine attacks more unpredictable and often worse. The instability of hormones during this time lowers the brain’s pain threshold, making women more susceptible to migraine attacks, particularly those sensitive to estrogen changes.
In menopause, hormone levels become more stable, though they remain low. For many women, this stability actually improves migraine frequency and severity, especially for those whose migraine attacks were closely tied to hormonal cycles. However, some women may continue to experience migraine attacks even after menopause, as the loss of reproductive hormones can itself impact migraine patterns.
—Dr. Natbony
Yes, if you have menstrual migraine, it is more likely that your migraine attacks will get worse during perimenopause. Women with menstrual migraine are especially sensitive to fluctuations in estrogen, which are characteristic of perimenopause. As a result, those with a history of menstrual migraine are much more susceptible to more frequent and severe migraine attacks during this transitional phase.
—Dr. Natbony
Yes, if you have menstrual migraine, there is a good chance your migraine attacks will improve after menopause.
About two-thirds of women experience improvement in migraine symptoms post-menopause, particularly those whose migraine attacks were triggered by hormonal fluctuations. The stabilization of hormone levels after menopause is often beneficial for women with a history of menstrual migraine.
—Dr. Natbony
Diagnosis and Treatment
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
Life Impact and Lifestyle Modifications
Feeling more anxious and depressed during menopause is common and can both worsen migraine and be worsened by migraine.
Address mood concerns proactively by speaking with your primary care doctor, seek support from a psychiatrist, and consider therapy.
There are also medications that can help manage both mood and migraine. Aggressively treating mood symptoms is important, as reducing anxiety and depression can decrease one of the significant triggers for migraine.
Addressing mood should be part of a holistic approach, alongside other migraine management strategies, to improve overall well-being during perimenopause and menopause.
—Dr. Natbony
Lifestyle factors such as diet, sleep, and exercise are crucial in managing both menopausal symptoms and migraine attacks.
I consider these foundational to any comprehensive treatment plan. Regular sleep is particularly important but can be difficult if night sweats or hot flashes disturb your rest. Prioritize consistent sleep schedules, eat healthy, stay hydrated, and maintain regular physical activity.
Exercise is especially important as we age, supporting overall health and potentially reducing migraine frequency and severity.
Techniques like pacing yourself, stress management, and incorporating mind-body practices (such as biofeedback, yoga, or meditation) can also help improve sleep quality and reduce symptoms.
While lifestyle changes alone may not eliminate migraine attacks, they significantly support other treatments and improve quality of life during menopause.
—Dr. Natbony
The best way for a patient to track their symptoms is by keeping it simple and consistent. Mark the days you have a migraine, track your menstrual cycle (if applicable), and note any hormonal symptoms—such as hot flashes or sleep disturbances—in a calendar or a notes app on your phone. This high-yield tracking provides clear, actionable data without being overwhelming.
A Migraine Action Plan is a valuable tool for both patients and doctors. It outlines specific steps to take during a migraine attack, including acute and preventive treatments, and provides backup options if the first steps don’t work. This plan reduces anxiety by making next steps clear for the patient, ensuring they know what to do even if they can’t immediately reach their doctor. For clinicians, a Migraine Action Plan and clear symptom tracking help guide treatment adjustments, monitor effectiveness, and improve the partnership between patient and physician.
—Dr. Natbony
About the Doctor
Lauren R. Natbony, MD, FAHS, is the Founder & Medical Director of Integrative Headache Medicine of New York. She is also an Assistant Clinical Professor of Neurology in the Division of Headache and Facial Pain at Mount Sinai’s Icahn School of Medicine. Dr. Natbony, who suffers from migraine herself, previously served as the Director of the Headache Medicine Fellowship at Mount Sinai and continues to be actively involved in teaching headache fellows and neurology residents. She is board-certified in Neurology by the American Board of Psychiatry and Neurology and in Headache Medicine by the United Council of Neurologic Subspecialties. CLICK HERE to learn more about Dr. Natbony and her medical practice!
This educational project was made possible in part by a generous donation from:
