Menopause and Migraines
What is Migraine?
Migraine is an inherited, or acquired combined disorder of the nerve and vascular tissue of the brain. The manifestation of this disorder is the headache, which occurs intermittently as a result of a stimulus or "trigger." In those affected, the frequency can vary markedly, and the headaches can occur rarely or on a daily basis. Common triggers include, odors, flashing lights, stress, lack of sleep and other various stimuli. Hormones can act as a trigger and a common variety of this is what is called "menstrual headache." This type of migraine is usually related to the fall in estrogen levels that occurs prior to menstruation. It is also likely that progesterone sensitivity plays a role as well in many women.
I have recently become menopausal and I am having trouble with migraine headaches. Why?
If migraine headaches occur initially, or become significantly worse following menopause, especially a surgical one, the possibility that it is related to your menopause and its associated hormonal alterations is certainly a reasonable consideration.
Is this because of my hormone replacement therapy / HRT?
When migraine occurs in post menopausal women there a number possibilities that can be considered.
Migraine usually does not occur as a result of estrogen itself, but rather changes in estrogen levels. The fall in estrogen levels that occurs at menopause can trigger migraine. This is particularly true when the menopause is surgical and the fall in hormone levels is abrupt. Regimens in which the estrogen levels vary widely, such as estrogen injections given on a monthly basis can potentially trigger migraine as the estrogen levels are very high immediately following the injection and fall off rapidly.
In some instances women who take oral estrogen preparations suffer from migraine triggered by substances produced as a byproduct of the inherent "first pass liver metabolism" of oral estrogen.
If the woman has a uterus and the headaches occur during the time she is taking the progesterone component of her hormone replacement therapy regimen, one would expect that they are due to either the progesterone, which has anti estrogenic affects, and/or falling estrogen levels if her regimen includes stopping her estrogen prior to her withdrawal bleeding.
What to do?
The first thing to do would be to see a neurologist to make sure that the headaches are not due to another problem. The neurologist can also discuss whether it would be better to treat the individual headaches if they do not occur too frequently, or to prescribe preventative therapy if they do.
Should I change my hormone replacement therapy / HRT regimen?
It would make sense to use a non oral regimen of hormone replacement therapy, preferably one that results in consistent hormone levels. Ideally, this would be an estrogen patch or gel, or subcutaneous hormone implants. Some menopausologists feel that migraine can occur as a result of testosterone deficiency especially when there has been a surgical removal of the ovaries and have had some success by replacing testosterone levels along with estrogen. Physicians who use subcutaneous hormone implants may be particularly successful when this is the problem. They are able to replace the estrogen and testosterone in a manner where after the initial rise in hormone levels occur, the day to day change in hormone levels is fairly small. I had some success using this method in selected patients, however the headaches returned when the hormone levels dropped below a critical point which was unique to each individual. At that time, ideally, implantation of hormones would be repeated. Testosterone patches in appropriate doses for women are not made in the United States, and so one of the available male replacement patches would have to be cut to an appropriate dosage size or a testosterone gel would have to be obtained from a compounding pharmacy. In either case, blood could be drawn to monitor levels to ascertain that the levels are in the desired range.
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