The changes that occur during menopause are called perimenopause. During perimenopause, there are ups and downs with how the ovaries work. When these changes happen in the ovaries, estrogen and progesterone fluctuate and can cause migraine attacks to come on or worsen.

Estrogen is the main culprit, causing hot flashes, migraine attacks, and changes in brain chemicals such as serotonin. In my experience and according to studies, women who have migraine related to hormonal changes such as menstruation, pregnancy, and birth control are more likely to have migraine worsen around the perimenopausal period.

The type of menopause that you go through also has an impact on whether migraine may worsen or improve. There is about a 50% to 60% chance that migraine will improve if you have gone through natural or spontaneous menopause. Women who have surgical menopause with the removal of the ovaries may have worsening migraine.

It’s very hard to predict how long the perimenopausal period can last. While the average is around 4 to 8 years, it can be much shorter or much longer based on individual genetics and hormonal changes.

Any sudden shifts in estrogen and progesterone can trigger or produce a worsening of migraine, not only estrogen withdrawal.

Many ask me: If up and down hormones are the issue, why don’t we start hormone replacement therapy? Well, I’m here to say that it is not that easy. Migraine is caused and triggered by many factors, including genetics, stress, changes in sleep, weather, foods, and changes in hormones.

These are just a few of the factors to consider. While hormonal fluctuations are a piece of the migraine jigsaw puzzle, science shows us that a few different factors contribute to the worsening of migraine attacks.

Hormone replacement therapy has been controversial because it can be unpredictable due to the side effect profile, there may be an imbalance between the body’s estrogen and the way that hormonal therapy is administered (patch, tablet, etc), and it hasn’t been shown to be helpful in treating migraine in studies.

The standard way to treat migraine related to menopause is by considering preventive treatments such as calcitonin gene-related peptide blocking medications, blood pressure medications, seizure medications, antidepressants, or onabotulinum toxin A and acute.

Treatments such as triptans, gepants, ditans, ergotamine derivatives, and nonsteroidal anti-inflammatory medications should be considered as needed.

In my experience, migraine attacks can be more severe around menopause and menstruation. Migraine attacks can consist of four different phases: the prodrome phase, the aura phase, the headache phase, and the postdrome phase.

The headache phase consists of pain on one or both sides of the head associated with sensitivity to light and loud noise, nausea and/or vomiting, and the need to rest. It is the most disabling phase. Each phase of migraine is different and can impact a person with migraine in different ways.

The prodrome phase can cause irritability, depression, food cravings, trouble concentrating, fatigue, and many other symptoms. The aura phase can cause neurological symptoms such as changes in vision, numbness, weakness, or difficulty speaking. The postdrome phase can cause trouble concentrating and fatigue.

Perimenopause can last 4 to 8 years on average but can vary based on a person’s own genetic makeup. While hormone fluctuations continue, migraine attacks typically continue, especially without appropriate treatment.

Migraine can be divided into episodic migraine and chronic migraine based on how many days a month you experience migraine attacks.

Experiencing less than 15 headache days a month is episodic migraine while experiencing 15 or more headache days a month is more consistent with chronic migraine. Individual migraine attacks usually last 4 to 72 hours but can be shorter or longer, especially if you do not have an optimal as-needed treatment plan.

Magnesium at a dosage of 600 milligrams (mg) a day has been shown to help reduce the overall number of migraine days. Magnesium is an important factor in the body. It is responsible for making proteins, energy production, and muscle function, among other things.

It also stabilizes the electrical activity within the brain. Studies have shown that people with menstrual migraine and classic migraine tend to have lower levels of magnesium. The most common side effect I see with magnesium is diarrhea and an upset stomach.

To avoid this, I often recommend starting at low doses such as 100 or 200 mg at bedtime daily and steadily increasing it over several weeks to allow the body time to adjust.

Initiating supplements or any treatments for migraine should be done with assistance from your doctor, as even supplements can interact with your existing medications or your own body’s chemistry.

Seeing a doctor as early as possible has many benefits. By initiating prevention for migraine early, you can cut down on your overall monthly attacks, reduce your disability, and prevent your migraine attacks from becoming chronic in nature.

It is especially important to see a doctor urgently in the emergency department if you have new changes in your vision, numbness in your face, arms or legs, weakness in your face, arms or legs, changes in your speech, a sudden onset headache, or a change from your usual headaches that alarms you.

Your doctor may need to perform a neurological exam, order blood work, and possibly take pictures of your brain with a computed tomography (CT) scan or magnetic resonance imaging (MRI).

It can always be helpful to start out with your primary care professional. Your primary care professional can perform an initial evaluation and refer you to another healthcare professional if needed.

Headache specialists are typically doctors who have completed medical school and a residency in neurology, internal medicine, or family medicine. They go on to complete additional training in Headache and Facial pain for 1 to 2 years and take an exam to become certified in this field.

Headache specialists often prescribe medications, perform procedures, and offer counseling on different integrative medication approaches to migraine management.

Headache specialists across the United States can be difficult to come by, but if you are able to snag an appointment, hold on tight and never let go!

Dr. Deena Kuruvilla is an ABMS board certified neurologist and a United Council for Neurologic Subspecialties (UCNS) certified headache and facial pain specialist. Dr. Kuruvilla has special interests in procedural and complementary and integrative medicine.