Perimenopausal Headaches
Typical Causes, Treatments, and Risks
I began writing about women’s hormonal health when I was 45 years old. That means I have been writing about perimenopause and experiencing it at the same time. I was interested in raising women’ awareness of the late-reproductive stage because I had the same unhelpful conversation with my doctor that so many other women do. The conversation that ends with, “well, you’re in your 40s now,” and a shrug.
Headaches have been a prominent symptom for me in the late-reproductive stage and in early perimenopause. Before my 40s, I had the occasional tension headache usually caused by eye strain. But in the last five years headaches have become a regular feature of my life. And these headaches are different.
Worsening headaches.
It turns out I am not alone. As many as 59% of women experience headaches. The vast majority of those headaches are migraines. For women who have already been diagnosed with migraine this might be an increase in the number of migraines. Other women like me, will have migraines for the first time in their 40s.
This uptick in headaches occurs early in the perimenopausal transition, with the highest incidence being in early perimenopause. But women also report an increase in headaches across all stages of the perimenopausal transition. Typically, headaches cluster around ovulation and the menstrual period, but some women experience other triggers such as weather changes, alcohol, and certain foods.
Estrogen and headaches.
Longtime readers won’t be surprised to hear that fluctuating estrogen levels are responsible for the increase in headaches women experience. In fact, women are two to three times more likely to experience migraine headaches than men are. Headaches are most common among women during puberty and perimenopause—both times when estrogen levels are fluctuating significantly. In perimenopause, estrogen levels can be sky high one day and plummet just a day or two later.
Estrogen acts in the brain to raise the threshold for developing a migraine. Dropping estrogen creates the right combination of hormones and neurotransmitters in the brain to kick off headaches. That is why headaches tend to happen around ovulation and the menstrual period when estrogen levels drop.
Managing headaches.
The fact that headaches are related to dropping estrogen and not just low estrogen levels has important implications for managing them. Hormone therapy in the form of an estrogen patch and daily progesterone may actually make headaches worse in the late reproductive stage and early perimenopause because it just adds estrogen to the already high levels circulating in the blood.
Instead, low-dose birth control pills may be more helpful. That’s because, along with ovulation, birth control pills suppress the production of estrogen in the ovaries. The pill then provides a stable level of estrogen that can help keep headaches at bay. Sometimes it’s helpful to take the pill continuously, skipping the sugar pills because some women will get headaches while taking the sugar pills.
Of course, medications typically used to treat and prevent migraine headaches at any reproductive stage can also be helpful in perimenopause. Many women will find that over-the-counter medications like ibuprofen or Excedrin get the job done. But if those medications aren’t doing the trick, you can talk to your doctor about using a prescription medication like a triptan to manage your symptoms.
Women who are experiencing very frequent headaches may want to see a headache specialist and consider taking medication to prevent migraines from occurring in the first place. Some medications used to prevent migraines like venlafaxine (Effexor) can also improve vasomotor symptoms for some women, giving you a little more bang for your buck.
Migraines with aura and hormone therapy.
Of course, any time we talk about hormones and a migraine, the topic of migraine with aura and stroke will come up as well. Aura is symptoms like visual changes, tingling fingers, or a taste in the mouth that happen just before a migraine headache. That’s because many years ago researchers noted an increase in the incidence of stroke among women with migraine with aura who were taking birth control pills. For years women were told that if they have migraine with aura, they shouldn’t take birth control pills. Some doctors worried hormone therapy might do the same.
However, the original data comes from women taking first generation high-dose birth control pills. Modern low-dose pills contain a fraction of the estrogen those older pills did. And stroke risk among women in their 40s is quite low, just 0.82 per 10,000 person years. As a result, migraine with aura is no longer a contraindication to taking birth control pills. Instead, women should have a conversation regarding the benefits and risks of taking birth control pills in their specific case.
There is no evidence that estrogen in the doses used for hormone therapy increase stroke risk. As a result, hormone therapy is safe for most women with migraine with aura.
The good news.
Headaches that began or got worse in perimenopause are often temporary. As women progress into menopause, headache frequency typically improves significantly. Particularly, once estrogen levels are stably low.
The Savvy Short:
Headaches, particularly migraines, are a common symptom during the perimenopausal transition. They are most common during the late-reproductive years and early perimenopause.
Estrogen levels that swing from very high to very low, which are common early in the perimenopausal transition, create the right environment in the brain for migraine headaches to occur.
Both typical treatments for migraine and vasomotor symptoms—often in the form of birth control pills—can help reduce migraine frequency and manage symptoms.
Headaches often become less frequent and less severe as women progress into menopause and estrogen levels stabilize.
I also notice sinus pain/pressure has increased and tends to ebb and flow with my cycle.