Perimenopause and Migraines

Episodes may increase during this transitional period in your life

If you're like many women, perimenopause—the years during which you transition to menopause—may be an overwhelming time filled with irregular menstrual cycles, hot flashes, vaginal dryness, mood disturbances, and difficulty sleeping. In addition to all of these symptoms, this seemingly daunting time may be made worse by an increase in migraine frequency.

Here's why and what you can do to manage your migraines as you get closer to menopause.

Changes During Perimenopause

The early stages of perimenopause are characterized by fluctuating estrogen levels and shorter menstrual cycles. As you progress into late perimenopause, your estrogen levels start declining, and you develop more menstrual irregularities like missed periods, in addition to symptoms like hot flashes, night sweats, insomnia, and vaginal dryness.

Symptoms of perimenopause
Verywell / Madelyn Goodnight

These symptoms are classic ones that you may be expecting, but hormone changes during perimenopause can give way to other, perhaps more surprising concerns as well, such as the onset or increased frequency of migraines.

When you stop menstruating for one year, you're officially in menopause, which means that your body is producing much lower levels of sex hormones and your reproductive years are behind you.

When Does Perimenopause Start?

Most women enter perimenopause in their 40s (the average age is 47) and reach menopause in approximately four years. However, you can start having premenopausal symptoms as early as your mid- to late-thirties, and perimenopause can last for up to 10 years for some women.

Why Migraines Increase

A 2016 study in the journal Headache used data from the American Migraine Prevalence and Prevention (AMPP) study to look at whether or not migraines increased during perimenopause for female migraineurs. Sure enough, the researchers found that for the 3,664 women involved in the study, the risk for developing high-frequency migraines during perimenopause—defined as having 10 or more migraines per month—was greater than it was for women with migraines who were still in the premenopausal stage (prior to perimenopause and menopause).

Other studies have found that some women actually first start getting migraines during perimenopause. By the time women reach menopause, about 40% of them have had a migraine at some time in their life.

Symptoms of perimenopause and migraines.
Maritsa Patrinos / Verywell

A precise explanation for why migraines increase during perimenopause is unclear, but experts suspect the following factors:

  • Hormonal fluctuations: The aforementioned hormonal changes that occur during perimenopause—specifically the decline in estrogen—may be an explanation. This estrogen decline is also linked to a decline of serotonin (a neurotransmitter) in your brain, which can disrupt the function of a cranial nerve called the trigeminal nerve, which then triggers a migraine. Hormonal fluctuations may especially be a factor if you're one of the up to 70% of women who have migraines that are associated with your menstrual cycle.
  • Heavier periods: Perimenopause can often cause you to have heavier blood flow during your period, which can lead to iron deficiency, another possible migraine trigger.
  • An increase in prostaglandins: Heavy menstrual flow is also linked to an increased prostaglandin release in the body. Prostaglandins are involved in a number of processes, including allowing your uterine lining to shed, as well as inflammation and blood vessel dilation, both of which can contribute to migraines.
  • Disrupted sleep: You may notice that you're not sleeping as much as you used to or that your sleep is often disrupted when you're in perimenopause. Both of these concerns are known triggers for migraines.

Keep in mind that not everyone experiences worse migraines during perimenopause. Though many women see an increase, some find there's no change.

Improvements After Menopause

Scientific studies are somewhat conflicting as to whether migraines improve when you're postmenopausal.

Experts suggest that the conflicting studies (some show migraines improve after menopause and others show they worsen) imply that other factors determine the likelihood of migraines after menopause. Some of these influences include:

  • Depression: Having clinical depression may increase your risk of having more migraines after menopause.
  • Pain medications: Using pain-alleviating medications to relieve menopause-related symptoms like muscle or joint pain could trigger medication-overuse headache.
  • Number of migraines: Whether you have episodic migraine (fewer than 15 migraines per month) or chronic migraine (15 or more migraines per month) by the time you reach menopause may make a difference. Migraines tend to improve significantly after menopause with episodic migraine, but they usually get worse if you have chronic migraine.
  • Speed of hormonal changes: During perimenopause, your ovaries decrease their production of estrogen and progesterone. The more slowly they do this, the more improvement you're likely to see in your migraines, both during perimenopause and postmenopause. Conversely, rapid hormonal fluctuations seem to create the opposite effect.
  • Spontaneous or induced menopause: A number of studies have shown that surgically-induced menopause, meaning that you've had your ovaries removed, is associated with migraines getting worse in a large percentage of women. This may be due to the sudden, huge shift in hormone levels, as well as the use of estrogen replacement therapy after surgery, which can actually make migraines worse in some women. However, when you go through spontaneous, natural menopause, your migraines are much more likely to improve.

Most women can expect to see improvement in their migraines after menopause, probably due to much more stable, though significantly lower hormonal levels.

Treating Your Migraine Attacks

The good news is that there are therapies to help you if you notice more migraine attacks as you near menopause. For instance, adopting healthy sleep habits, eating well, daily aerobic exercise, and stress management may be helpful for your migraines and will also improve your overall health. In addition, your healthcare provider may consider a migraine preventive medication.

Hormone replacement therapy (HRT) at the lowest effective dose may be used during perimenopause or early menopause to relieve hot flashes and vaginal atrophy. Its effect on migraine prevention during perimenopause or menopause is controversial, with some studies showing worsening of the migraines during HTR. In addition, there is the potential for increased risk of strokes and heart attacks with HTR. If HTR is considered, low doses used continuously is preferable, and the patients should be counseled about potential side effects.

Other medications, such as, venlafaxine, escitalopram, paroxetine, and gabapentin as well as non-medication strategies (acupuncture, aerobic exercise, yoga) can be helpful in some perimenopause patients by not only decreasing migraine frequency, but also improving mood and vasomotor (hot flashes) symptoms that are common during this period of time.

While hormone therapy can do wonders for some women, it does carry some health risks and may not be appropriate for you based on your medical history. A thoughtful conversation is needed with your personal physician before this can be prescribed.

A Word From Verywell

Perimenopause is a hallmark period of time that signals a decline in estrogen in your body. While the physical and mental changes that occur may be anxiety-provoking, remember that you're not alone—thousands of other women are experiencing perimenopause right along with you. Remember, too, that perimenopause and menopause are not health conditions. Rather, they're stages of reproductive aging—parts of the journey of being a woman.

If you believe you're nearing menopause, check in with your healthcare provider for a consultation on how you can manage your symptoms, including migraines and other menopausal-related symptoms like hot flashes. Your healthcare provider can also give you information on how to best care for your body, especially your heart and bones, which can be affected by the hormonal and age-related changes of menopause.

9 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
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Additional Reading

By Colleen Doherty, MD
 Colleen Doherty, MD, is a board-certified internist living with multiple sclerosis.