Perimenopause, Menopause, and Migraine: What You Need to Know to Take Control
If you’re a woman who’s been struggling with migraine attacks and are now noticing changes as you approach your 40s, 50s, or beyond, you’re not alone—and there’s hope!
Migraine is more than just a headache – it’s a complex neurological disease that can affect your entire life. This blog is based on a live webinar interview with Dr. Lauren Natbony, a certified headache specialist and the medical director of Integrative Headache Medicine of New York. Dr Natbony is passionate about making a difference in the lives of women going through perimenopause and menopause. She explains, “Migraine is not just a headache, it’s a disease and it’s debilitating and horrible in so many ways.” For many women, migraine patterns shift dramatically during this time of their lives, making it especially challenging to manage. However, understanding what’s happening in your body and knowing your options can empower you to advocate for yourself and work more effectively with your headache doctor.
What Is Perimenopause and Menopause?
Perimenopause is the transitional phase “around menopause” when your estrogen and progesterone levels start fluctuating and becoming more irregular. Dr. Natbony defines perimenopause: “The transitional phase when the estrogen and progesterone levels start to fluctuate and become more irregular. It can begin as early as your late 30s or early 40s, and lasts about four to eight years on average.” These hormonal ups and downs can make migraine attacks more unpredictable and often worse because, as she notes, “Migraine likes stability, but this is a time of the least amount of stability where everything becomes irregular.”
Menopause itself is officially diagnosed after you’ve gone 12 months without a menstrual period. The average age for menopause in the U.S. is around 51, but it can vary based on your family history.
How Do Hormonal Changes Affect Migraine?
Estrogen plays a significant role in migraine attacks. Dr. Natbony explains, “Estrogen has a really powerful effect on our pain pathways, on serotonin receptors, and when estrogen drops rapidly or is erratic, the brain’s pain threshold lowers, and it just becomes much more susceptible.”
Women who have menstrual migraine are particularly sensitive to hormonal changes. Overall, approximately 60% of women experience worsening migraine during perimenopause, and about two-thirds notice improvement after menopause when hormones stabilize. Dr. Natbony explains, “Around two-thirds of women improve after menopause… especially for those people who were more triggered by hormones, the hormone stabilization phase that comes after menopause is helpful.” However, migraine frequently persists after menopause, and older women may experience less typical migraine presentations, including an increased prevalence of vestibular symptoms and aura without headache.
Migraine Treatment Options: A Personalized Approach
Managing migraine during perimenopause and menopause requires a personalized, precision-based approach. Dr. Natbony describes her practice as integrating “all parts of someone’s life into their treatment plan,” including collaboration with patients’ OB-GYNs.
Hormone replacement therapy (HRT) can help some women, especially with symptoms beyond migraine, but it’s not a guaranteed migraine fix. Dr. Natbony notes, “Transdermal estrogen, which is what’s usually used with hormone replacement therapy, tends to be safer and also more stable for those with migraine than oral estrogen… We usually say to use the lowest effective dose of estrogen and maintain steady states rather than cycling of any hormones.” However, HRT isn’t suitable for everyone, especially women with stroke risk factors or a history of breast cancer. In addition, it’s not always helpful: “I’ve also seen patients who really didn’t have migraine before, were put on hormone replacement therapy, and now have horrible headaches from it… It’s really dependent on the person.”
Important to note is that surgical menopause, such as ovary removal, can worsen migraine. Dr. Natbony cautions, “Taking out the ovaries… is the worst for migraine because it’s an abrupt change… Studies have shown that actually taking out the ovaries does absolutely nothing, if not worsen migraine. So I would say if you’re going to do that for a medically necessary cause, then absolutely, but for migraine, please don’t.”
For women who cannot or prefer not to use hormones, many other options exist:
- Medications: Dr. Natbony often uses combination or “layering” approaches: “If you’re on a beta blocker, maybe I’m also going to add a gepant or a CGRP monoclonal antibody, or maybe I’ll add Botox on top of that… I more often need to pile options on rather than just leave it at one thing or change it.” This is considered the toolbox approach.
- Supplements: Magnesium glycinate is a favorite: “Magnesium is great for migraine prevention… especially around perimenopause, because magnesium levels shift more during hormonal fluctuations… I typically recommend magnesium glycinate because it’s the most bioavailable and best tolerated… with the goal dose being around 400 to 600mg a day.” Other supplements like riboflavin (vitamin B2), coenzyme Q10, and vitamin D also have evidence for reducing migraine frequency and severity, including in women experiencing hormonal shifts and perimenopause.
- Medical Devices: Interestingly, Dr. Natbony states, “Every single one of my patients gets a device, because it’s sort of one of those, why not?… I love devices!” She mentions FDA-cleared options such as Nerivio, Cefaly, gammaCore, and others, emphasizing, “If you’re a person who can dedicate the time to use a device, please do.”
- Lifestyle & Integrative Therapies: Not surprisingly, given the name of her practice, Dr. Natbony recommends utilizing mind-body techniques such as biofeedback, yoga, meditation, and acupuncture. And she describes lifestyle as “basically the foundation of everything,” stressing the importance of regular sleep, regular meals, hydration, and exercise.
Tracking and Planning: Your Migraine Action Plan
Keeping track of migraine attacks and symptoms can be daunting, especially with brain fog. However, keeping track of at least the basics in a Notes app or calendar can be very helpful. Additionally, having a personalized Migraine Action Plan is crucial. Dr Natbony explains about the migraine action plan, “It gives a clear breakdown of what you should do. I always have a step 1, a step 2, a step 3… If something doesn’t work, we have a backup, and a backup to the backup.” This reduces anxiety and helps patients feel supported, even when their doctor isn’t immediately available, enabling better communication and more effective treatment adjustments.
Final Thoughts: Don’t Settle for “Just Aging”
Many women have been told that worsening migraine during perimenopause or menopause is just something to accept as “part of getting older.” Dr. Natbony emphatically says, “You don’t have to settle for ‘this is just aging.’ There are tools and treatments that can help. It’s just finding what precisely works for you… Just because you’re going through different stages of life shouldn’t mean you shouldn’t be getting the best care.” And she adds an incredibly validating message for women, “You are not imagining things. These are real things that are happening; your brain is responding to real biological changes.”
So if you are a woman going through perimenopause or menopause and struggling to manage your migraine, remember: You know your body best. Your symptoms are real, and help is available. Don’t hesitate to seek care from a certified headache specialist and OB-GYN familiar with this complex interaction of hormones and migraine. Educate yourself on the available options for migraine during this time. And know that you don’t have to face this alone!
Let Us Know:
Have you experienced changes in your migraine attacks during perimenopause or even once in menopause? Has anything helped you? Did you find your headache doctor receptive to the challenges you faced during this time? What are your best tips for other women going through this?