Understanding and Treating Headache Related to Menopause
by Deena Kuruvilla, MD
A large number of patients in my headache practice are either perimenopausal or postmenopausal. Many of those who are perimenopausal believe they will be cured of migraine after completing the hormonal fluctuations of menopause. This month’s featured article states that evidence certainly speaks against this generally held theory. Clinic based studies show that in 24.4%, headache improved with menopause while in 35.7%, it worsened.
In the journal, Current Treatment Options in Neurology, Dr. Lauritsen and colleagues review the associations between migraine and the menopausal period as well as which treatments have evidence. Epidemiological studies have shown that migraine is much more common in women than men and many connections between hormones and headaches have been established. Menopause is diagnosed 12 months after a woman’s final menstrual period. The average age for natural menopause is 51. According to the article, migraine is reported in 10-29% of menopausal women and is associated with greater disability and a higher incidence of mood disorders.
The stages of menopause include changes in menstrual bleeding as well as changes in the pituitary gonadotropin follicle-stimulating hormone (FSH). Menopause is characterized by wide variability in both FSH and estradiol in the blood, so changes in the circulating levels of these hormones are not consistent indicators of menopausal status during perimenopause. As menopause progresses, the ovaries produce less estrogen, and this drop in estrogen has important effects on various organ systems including the head.
One of the most common questions posed to me is regarding the utility of hormone therapy (HT) for treating headache. Our article cautions that HT in postmenopausal women corresponds to increased headache compared to women who were never on HT. In women with migraine, the highest rate of migraine corresponded to systemic use of HT as opposed to locally administered HT. More specifically, a higher risk of migraine was seen with systemic estrogen and combined systemic estrogen and progesterone HT. This same risk is not seen in locally administered estrogen only HT. Population studies in post-menopausal women have shown that risk factors for migraine include younger age overall, younger age at menopause, current use of HT and a history of surgical menopause. Nappi et al. conducted a randomized prospective open label trial which confirmed that both the frequency of attacks and headache days were increased with oral HT and as needed analgesic use was increased. Estrogen containing HT can increase the risk for cardiovascular disease and stroke, especially in patients with migraine with aura. The authors recommend, if HT is pursued, continuous rather than cyclical doses should be used and a transdermal route is recommended.
Non hormonal based treatments that have some evidence include antidepressants such as venlafaxine, paroxetine and escitalopram and an anti-seizure/neuropathic medication, gabapentin. Complementary and integrative options which include acupuncture, black cohosh, vitamin E, aerobic exercise and yoga have also proven to be helpful in limited studies.